Failure to Consistently Implement Pressure Ulcer Prevention and Treatment Orders
Penalty
Summary
A resident with multiple complex medical conditions, including Parkinson's disease, dementia, chronic pain, and a history of partial toe amputation, was identified as being at moderate risk for skin breakdown based on a Braden scale score of 13-14. The resident had existing pressure ulcers on his toes and was under physician orders for specific wound care treatments and preventative interventions, such as the use of foam boots, silicone toe spacers, and a bed cradle to relieve pressure and prevent further skin breakdown. Despite these orders, observations revealed that the resident was not consistently provided with the prescribed interventions. For example, the resident was repeatedly observed in a recliner without protective boots, and gripper socks were seen on his feet despite orders against their use. Additionally, the silicone spacers intended to separate his toes were not always in place, and there were instances where alternative materials were used due to missing spacers. Review of the treatment administration record (TAR) showed multiple missed or undocumented wound care treatments and preventative measures, including the application of foam boots and wound dressings. Staff interviews indicated confusion regarding the timing and application of protective boots, with some staff believing they were only required in bed, while orders specified use in the morning, evening, and nighttime. There was also a lack of clarity among staff about the use of socks and the need for continuous toe separation. Documentation further revealed that the resident developed new pressure ulcers on additional toes during his stay, with the likely cause identified as continuous pressure between the toes, exacerbated by inconsistent use of spacers and protective devices. The facility's own pressure ulcer prevention and treatment policy required regular skin assessments, implementation of prevention protocols based on Braden scores, and the use of pressure-reducing devices as ordered for all settings, including recliners. However, these protocols were not consistently followed for this resident. The failure to implement and document ordered treatments and preventative interventions led to the development of new pressure ulcers and the lack of consistent care for existing wounds.