Failure to Apply Heel Protectors as Ordered for Pressure Injury Prevention
Penalty
Summary
A deficiency was identified when staff failed to follow a physician's order for a resident who was at risk for developing pressure injuries. The resident, who had diagnoses including palliative care, polyneuropathy, and heart failure, required maximal assistance with hygiene and was dependent on staff for toileting and bathing. The resident's care plan included a physician's order for bilateral heel protectors to be applied while in bed as a preventative measure for skin maintenance. During an observation, it was noted that the resident's heels were in direct contact with the mattress and heel protectors were not in place, contrary to the physician's order. A CNA confirmed that the resident should have been wearing heel protectors to prevent skin breakdown. The DON also acknowledged that staff did not follow the physician's order and emphasized the necessity of such interventions for residents with limited mobility. The facility's policy required the use of pressure-relieving devices to prevent pressure injuries, which was not adhered to in this instance.