Failure to Float Heels as Ordered for Pressure Injury Prevention
Penalty
Summary
Facility staff failed to follow physician orders and care plan interventions for a resident with a history of a deep tissue injury on the left heel. The resident, who was dependent on staff for all activities of daily living and had significant cognitive and physical impairments, had an order and care plan in place to float her heels on two pillows to prevent pressure injuries. During an observation, it was noted that the resident's heels were resting directly on the mattress, contrary to the prescribed intervention. A registered nurse confirmed during the observation that the resident's heels were not floated as required and acknowledged that the order to float the heels on two pillows was not followed by facility staff. The facility's policy on pressure ulcer management also indicated the use of appropriate pressure relief devices, which was not implemented in this instance.