Failure to Provide Ordered Heel Protectors for At-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for a resident at risk for pressure injuries. The resident, who had diagnoses including diabetes mellitus, failure to thrive, and paraplegia, was identified as being at moderate risk for pressure ulcer development due to impaired mobility, incontinence, and poor nutrition. The care plan and physician orders specified the use of bilateral heel protectors while the resident was in bed to prevent pressure injuries. However, during observation, the resident was found in bed without the required heel protectors, with their heels instead placed on a pillow. Interviews with both an LVN and the DON confirmed that the resident should have been wearing bilateral heel protectors as per the physician's order and care plan. The facility's policy on pressure injury prevention also required staff to implement such interventions. The failure to provide the ordered heel protectors constituted a lapse in following prescribed care for a resident at risk for pressure injuries.