Failure to Implement Pressure-Relieving Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement and maintain appropriate pressure-relieving interventions for residents identified as being at high risk for pressure injuries. For one resident with a history of diabetes, peripheral vascular disease, and an unstageable sacral pressure ulcer, staff did not consistently offload the resident's heels as required by the care plan, despite the resident being at high risk for pressure injuries. Observations showed the resident's legs and heels were directly on the mattress without protective devices, and the resident reported that staff had not recently offered to place anything under his legs. The resident's family was not informed of any refusals, and staff interviews confirmed that offloading should be reattempted if initially refused. Another resident, who had an order for heel suspension boots to be worn in bed or in a wheelchair every shift, was observed with only one boot in place and no documentation of refusal. Staff confirmed the boots were necessary to prevent new wounds, especially given the resident's tendency to cross her legs, which impairs circulation. A third resident, at high risk for pressure injuries due to Parkinson's disease and decreased mobility, was observed multiple times with his heels and feet directly on the footrest of a recliner without any protective devices, contrary to the care plan and facility policy. The facility's own wound care guidelines require offloading of heels, but this was not consistently implemented for these residents.