Failure to Implement Physician Orders for Pressure Ulcer Prevention
Penalty
Summary
Staff failed to follow physician orders for pressure ulcer prevention for one resident with a history of heart failure, pancytopenia, encephalopathy, and muscle weakness. The resident was identified as at risk for skin breakdown, with a Braden Scale score of 17 and documented stage 1 pressure ulcers on both heels. Physician orders were in place for the application of skin barrier film every shift and for protective boots to be worn on both feet every shift to prevent further skin breakdown. Despite these orders, multiple observations over several days found the resident lying in bed without heel protectors. Interviews with nursing staff confirmed the resident was not wearing the prescribed heel protective boots, and staff were unable to locate the devices in the resident's room. The Director of Nursing also confirmed the existence of the physician's orders and acknowledged that the boots should have been in use. Facility policy required interventions such as offloading heels to prevent pressure injuries, but these were not implemented as ordered.