Failure to Update Care Plan for Resident's Refusal of Pressure-Relief Boots
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan addressing a resident's refusal to wear physician-ordered Prevalon heel protection boots. Multiple observations over several days showed the resident resting in bed with non-skid socks and without the prescribed Prevalon boots, which were not visible in the area. The resident, who was cognitively intact and at risk for skin breakdown, reported refusing the boots because they were too hot. The clinical record included diagnoses such as traumatic brain injury, history of TIA, and gait abnormalities, and contained a physician order for the use of Prevalon boots while in bed with no end date. Despite the resident's ongoing refusal, the care plan was not updated to reflect this non-compliance or to address the resident's preferences and needs regarding the prescribed intervention. Staff interviews confirmed the resident's consistent refusal and acknowledged that the care plan should have been revised accordingly. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables, and for care plans to be revised as resident information or condition changes, which was not followed in this case.