Failure to Implement Pressure-Reducing Devices and Insulin Pen Dating
Penalty
Summary
The facility failed to implement pressure-reducing devices as ordered for two residents at risk for skin breakdown. One resident with severe protein-calorie malnutrition, dementia, and a stage 2 pressure ulcer of the sacral region had physician orders and care plans specifying the use of Prevalon heel boots at all times except during care. Despite documentation indicating compliance, multiple observations revealed the resident was not wearing the boots while in a wheelchair, and staff interviews confirmed a misunderstanding of the order, with nursing assistants believing the boots were only required at night. Another resident with diabetes, chronic kidney disease, and lymphedema had orders for heel offloading and off-loading boots when in bed. Observations over several days showed the resident did not have heels offloaded or boots in use, and staff confirmed the interventions were not being implemented as ordered. Additionally, the facility failed to ensure insulin pens were dated when opened for two residents requiring daily insulin injections. Facility policy and manufacturer instructions require insulin pens to be dated upon opening and discarded after 28 days. Observations and interviews confirmed that insulin pens in use for both residents did not have open dates, and staff, including the DON, acknowledged that this practice was not being followed, despite it being outlined in facility policy. These deficiencies were identified through record reviews, direct observations, and staff and resident interviews. The failures involved not following physician orders and facility policies regarding pressure injury prevention and medication management, specifically the use of pressure-reducing devices and proper labeling of insulin pens.