Failure to Implement Pressure Offloading Interventions for At-Risk Resident
Penalty
Summary
The facility failed to consistently implement physician-ordered interventions to offload pressure from a resident's heels, as required to prevent pressure ulcers. The resident, who had a history of dementia, a resolved left heel pressure ulcer, and was at moderate risk for developing pressure sores, had a care plan and physician order in place to use a heel manager while in bed. Despite these documented interventions, multiple observations over several days showed the resident lying in bed with her heels in direct contact with the mattress and without the use of a heel manager or any pressure-relieving device. Staff interviews confirmed a lack of awareness and implementation of the heel manager intervention, with one CNA unaware of the device and unable to explain why a pillow was not used, and an RN unable to locate the heel manager in the resident's room. The facility's own policies required systematic assessment and individualized care planning for skin integrity, including the use of pressure reduction devices as ordered. Documentation in the electronic medical record reflected the resident's risk and the need for heel offloading, but these interventions were not consistently carried out. The Director of Nursing acknowledged that the heel manager should have been in place as ordered to prevent further skin breakdown, confirming the lapse in following prescribed care and facility policy.