Failure to Apply Ordered Pressure-Reducing Devices for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to implement physician-ordered pressure-reducing interventions for a resident identified as high risk for pressure ulcer development. The resident had multiple diagnoses, including malnutrition, adult failure to thrive, cerebral infarction, and was receiving hospice care. The care plan and physician's orders specified that heel protectors were to be applied bilaterally when the resident was in bed, as a preventive measure. Despite these orders and a Braden Scale score indicating high risk, observations on multiple occasions revealed that the resident was in bed without heel protectors, with her heels resting directly on the mattress. The resident's boots, intended for pressure relief, were found in her chair instead of on her heels. Interviews with nursing staff confirmed that both nurses and CNAs had access to the care plan or Kardex, which included the intervention to apply heel protectors. Staff acknowledged that it was the CNA's responsibility to apply the boots and the nurse's responsibility to ensure compliance. The facility's policy required interventions for residents with a Braden score of 12 or less, but the required preventive measure was not consistently implemented, as evidenced by direct observation and staff statements.