Failure to Implement and Maintain Pressure Ulcer Prevention Interventions
Penalty
Summary
A resident who was admitted without pressure ulcers and identified as being at moderate risk for pressure sores developed deep tissue injuries (DTIs) on both heels during their stay. Despite being care planned for heel protection interventions such as floating the heels with pillows and the use of soft boots, multiple observations revealed that the resident's heels were consistently left in direct contact with the bed mattress, without the prescribed protective devices in place. The resident reported discomfort and confirmed that staff did not consistently implement the interventions intended to relieve pressure from his heels. Staff interviews and record reviews confirmed that prior to the development of the DTIs, only standard pressure ulcer prevention measures were in place, such as a pressure-reducing mattress, cushion, regular repositioning, and incontinence care. No additional heel-specific interventions were implemented until after the DTIs were identified. Documentation and staff statements indicated that the care plan interventions for heel protection were not reliably followed, leading to the development of pressure ulcers that were not present on admission.