Failure to Follow Physician Order for Heel Protection
Penalty
Summary
Licensed nurses failed to follow a physician's order to float a resident's heels while the resident was in bed. The resident, who was admitted with a diagnosis of protein-calorie malnutrition, had a physician order dated 11/4/24 requiring his heels to be floated with pillows at his calves or by using Prevalon boots whenever he was in bed. Observations on multiple occasions showed the resident lying in bed without pillows at his calves or Prevalon boots in place. During an interview, a registered nurse confirmed that the resident's heels should have been floated as per the physician's order, and acknowledged that this was not being done. The facility's job description for licensed vocational nurses includes providing basic wound care and treatments as ordered by healthcare providers.