Failure to Implement Pressure-Reducing Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure that pressure-reducing measures were implemented for a resident with significant risk factors for pressure ulcer development. The resident had multiple diagnoses, including hypertension, diabetes mellitus, COPD, muscle weakness, communication deficit, hemiparesis following a stroke, and severely impaired cognition. The resident was identified as being at high risk for pressure ulcers, with a Braden Scale score of 12, and had a history of pressure injury. Physician orders and the care plan specified the use of bilateral boots to be worn even while in bed, with removal every shift for skin checks, and the application of skin prep to the heels. Despite these orders, observations showed that the resident's heels were directly on the mattress without the prescribed boots in place. Interviews with nursing staff and review of facility policy confirmed that ensuring the application of pressure-reducing boots was a nursing responsibility, documented on the Treatment Administration Record (TAR), and could be delegated to CNAs with follow-through required by the nurse. The facility's policy outlined procedures for managing skin integrity and preventing pressure ulcers. However, the lack of adherence to these procedures and physician orders resulted in the resident being left without the necessary pressure-reducing devices, placing them at increased risk for pressure ulcer development.