Failure to Consistently Apply Ordered Pressure-Reducing Devices
Penalty
Summary
Surveyors identified that the facility failed to ensure the consistent application of physician-ordered pressure-reducing devices, specifically heel protectors and suspension boots, for two residents with significant risk factors for pressure ulcer development. One resident, with diagnoses including dementia, diabetes mellitus, and muscle weakness, had orders for bilateral heel suspension boots to be worn at all times when in bed, as well as instructions to encourage non-weight bearing on the right heel. Despite these orders, observations revealed that the resident was found in bed with her heels directly on the mattress and the suspension boots not in use. Staff interviews confirmed that the boots were not always applied, with a CNA expressing concern about falls if the resident attempted to ambulate while wearing them. A licensed nurse was unsure of the specific devices in place without checking the care plan, and administrative staff stated it was the responsibility of all staff to ensure devices were used as ordered. Another resident, with a history of cellulitis, hip fracture, muscle weakness, Alzheimer's disease, and existing stage 2 pressure ulcers, also had physician orders for heel protectors to be worn at all times when in bed. Multiple observations documented that this resident was in bed without heel protectors, with heels resting directly on the mattress. Staff interviews indicated that both nurses and CNAs had access to care plans and the Kardex, which outlined the need for heel protectors, and that it was the responsibility of both roles to ensure the devices were applied as ordered. The facility's own policy on skin integrity and pressure ulcer prevention required care consistent with professional standards to prevent pressure ulcers and to ensure the use of pressure-reducing devices as ordered. Despite this, the failure to apply the ordered devices as observed and confirmed by staff interviews placed both residents at increased risk for the development or worsening of pressure ulcers.