Failure to Update Care Plan and Implement Pressure-Relieving Interventions for Pressure Ulcer
Penalty
Summary
The facility failed to update the care plan and implement pressure-relieving interventions for a resident with a newly developed stage 2 pressure ulcer on the right heel. Despite the resident being identified as very high risk for pressure ulcer development due to conditions such as cerebral palsy, epilepsy, intellectual disabilities, and hypothyroidism, and being dependent on all activities of daily living, the care plan did not include the use of a pressure-relieving off-loading boot as recommended by the wound physician. Observations showed the resident's right heel was repeatedly resting on the wheelchair foot pedal, both with a sock and a tennis shoe, rather than being offloaded or protected as required. The wound nurse acknowledged that the resident should have been using a pressure-relieving boot to prevent further deterioration of the pressure ulcer, but this intervention was not implemented or communicated to the wound physician. The nurse also admitted responsibility for not updating the resident's care plan with new interventions to offload the heel, both in bed and while out of bed. The facility's own policies outlined the need for such preventative measures and equipment, but these were not followed, resulting in a failure to provide appropriate pressure ulcer care and prevention.