Failure to Provide Ordered Pressure Ulcer Care and Preventive Devices
Penalty
Summary
A deficiency occurred when a resident with a right outer ankle pressure injury was observed in bed without a dressing on the wound and without a Prevalon heel protector boot on the right foot. Certified nursing assistant (CNA) and registered nurse (RN) both confirmed during separate observations that the resident's pressure injury was not covered as ordered, and the heel protector boot was not in use, despite being present on the nightstand. The CNA acknowledged forgetting to verify and apply the boot, while the RN confirmed that the dressing had not been applied to the pressure injury at the time of observation. Record review showed that there were physician orders in place for daily cleansing and dressing of the pressure ulcer, as well as for the use of a Prevalon heel protector boot to the right foot. The facility's policy required redistribution of pressure and evidence-based treatments for residents with pressure injuries. The failure to follow these orders and policies resulted in the resident not receiving necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries.