Failure to Consistently Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to consistently implement planned interventions to promote healing and prevent the worsening or development of pressure ulcers for one resident. The resident in question was admitted with significant medical conditions, including diabetes and rheumatoid arthritis, and was assessed as being at high risk for pressure sore development due to severe cognitive impairment and dependence on staff for activities of daily living. The care plan and physician orders specified the use of heel-lift boots at all times, except during care, as well as the use of a specialized mattress and pressure redistribution cushion. Despite these documented interventions, multiple observations revealed that the resident was not wearing the required heel-lift boots on two separate occasions. Instead, the resident was found wearing slippers, and the heel-lift boots were observed lying unused in the room. Staff interviews confirmed that the resident often removed the boots, and staff would then put slippers on instead. However, there was no documentation in the care plan or task reports regarding the resident's refusal to wear the boots or any interventions taken to address these refusals. Additionally, staff documentation inaccurately indicated that the heel-lift boots were on the resident at times when direct observation showed otherwise. The Director of Nursing confirmed that the facility did not consistently implement the planned interventions to promote healing or prevent the progression of the resident's right heel pressure ulcer. This failure was found to be noncompliant with facility policy and regulatory requirements.