Failure to Consistently Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement prescribed interventions to prevent and promote the healing of a pressure injury for one resident. Multiple observations over several days showed that the resident, who was severely cognitively impaired and dependent on staff for mobility and care, was repeatedly found lying on his back in bed without his ordered moon boots, which are designed to offload pressure from the heels. Despite physician orders and care plan interventions specifying the use of moon boots while in bed and the need to float the resident's heels, staff did not consistently apply these devices. The moon boots were frequently observed on a chair or chest of drawers rather than on the resident, and his heels were not floated as required. Interviews with staff confirmed that the resident was supposed to have the moon boots on while in bed, and that this was a standing order signed off every shift. However, there was no documentation of the resident refusing the intervention, and staff acknowledged that the boots were not always applied. The resident's representative also reported that the resident was not repositioned for extended periods and that the moon boots were only used about half the time. The resident had a history of pressure injuries, including a stage 3 pressure injury on the left heel that developed after admission, as well as sores on his back and buttocks. Clinical record review indicated ongoing wound care treatments and preventative interventions, including the use of a pressure-relieving mattress, hydrophilic wound dressings, and regular wound assessments. Despite these measures, the lack of consistent application of the moon boots and failure to float the heels as ordered contributed to the deficiency. Facility policy required the use of specialty boots or floating heels for residents at high risk for skin breakdown, but this was not consistently followed for this resident.