Failure to Provide Ordered Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for two residents with pressure-related skin conditions. For one resident, observations revealed that her heels were not off-loaded as ordered while she was in bed, despite having wounds on her left foot. The wound nurse confirmed there was no current order for off-loading boots and stated she would contact the physician to obtain one. The resident's medical record indicated she was cognitively impaired, dependent for all activities of daily living, and at risk for developing pressure ulcers. A physician's order was in place to off-load heels while in bed and confirm every shift, but this was not followed. Another resident was observed without a dressing covering her sacral wound, which was open to air, and her heels were also not off-loaded as ordered. The wound nurse acknowledged the missing dressing and immediately applied one. During a subsequent wound treatment, the nurse failed to wear a gown despite the resident being on Enhanced Barrier Precautions, only realizing the omission after being prompted. The resident's record showed severe cognitive impairment, lower extremity impairment, and dependence on staff for care. Physician's orders required off-loading of heels and specific wound care, but these were not consistently implemented.