Failure to Obtain Order and Correctly Apply Heel Boots
Penalty
Summary
The facility failed to obtain a physician's order prior to the application of pressure redistribution/heel protector boots for a resident with multiple diagnoses, including dementia, foot drop, and lower leg pain. Observations on multiple occasions revealed that the resident was resting in bed with heel boots placed under their feet, but the boots were not fastened and the resident's heels were not positioned over the pressure redistribution opening as required. The clinical record lacked an order for the use and monitoring of heel boots, and there was no documentation of heel assessments or monitoring for pressure injuries or deep tissue injuries related to the use of the boots. Interviews with nursing staff and the DON confirmed that both nurses and CNAs applied the heel boots without a physician's order and that the boots were not correctly applied, as the resident's heels were not aligned with the opening. Staff explained that the boots were left unfastened due to the resident's sensitivity and preference, but acknowledged that an order was required and that the boots should have been properly positioned to prevent pressure injuries. Facility policy required orders for all equipment used in resident care and specified correct application of pressure redistribution devices, which was not followed in this case.