Failure to Follow Physician Orders for Heel Protectors Resulting in Deep Tissue Injury
Penalty
Summary
Facility staff failed to follow physician orders for a resident at high risk for pressure injuries, as evidenced by the resident not wearing ordered heel protector boots while in bed. Observations on two separate occasions found the heel protectors placed on the resident's nightstand or bedside table rather than on the resident, despite a physician order specifying their use for skin maintenance. Interviews with the Assistant Director of Nursing, a CNA, and an LVN confirmed that the heel protectors were not applied as ordered, and staff did not notify a nurse or assess the resident's skin as required. The CNA stated she did not apply the protectors because the resident did not have a dressing on her left ankle, and the LVN admitted to missing a skin assessment due to unfamiliarity with the resident. The resident had a history of peripheral vascular disease, limited ankle movement, and was assessed as high risk for pressure injuries with a Braden Scale score of 12. The care plan included interventions such as turning, repositioning, and use of pressure-reducing devices. Despite these documented risks and interventions, the resident developed a deep tissue injury (DTI) on the left lateral ankle, as noted in nursing progress notes. Facility policy required care to be provided in accordance with physician orders, which was not followed in this instance, as acknowledged by the Assistant Director of Nursing.