Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A resident with anoxic brain injury, contractures, and severe cognitive impairment was identified as being at high risk for developing pressure areas. The resident's care plan included wound care as ordered, and a physician's order specified the application of a foam dressing to the top of the right foot as a preventative measure. Additionally, a wound practitioner recommended the use of pressure-reducing boots at all times. During observation, the resident was found in bed without the pressure-reducing boots, which were instead on the bedside table. The preventative dressing was also not in place on the resident's right foot. An LPN confirmed that the boots and dressing were not being used and was unaware of the dressing order, though the order was verified in the electronic medical record. Facility policy required the use of appropriate supportive devices and regular review of interventions, but these measures were not implemented for this resident.