Failure to Apply Pressure-Reducing Devices for At-Risk Residents
Penalty
Summary
The facility failed to ensure that pressure-reducing devices were in place for two residents who were at risk for the development of pressure ulcers. One resident, with diagnoses including epilepsy, dysphagia, and dementia, was documented as having severely impaired cognition and was dependent on staff for mobility and activities of daily living. Physician orders and care plans specified the use of pressure-relieving boots on both lower extremities, but multiple observations over several days showed the resident without these boots while seated in a Broda chair and while in bed. Staff interviews revealed a lack of documentation and inconsistent communication regarding the application of these devices, despite the care plan and physician orders. Another resident, with a history of hypertension, anemia, Alzheimer's disease, diabetes, and other conditions, was also identified as being at risk for pressure ulcers due to incontinence and immobility. The care plan required the use of a foam mattress and floating of heels in bed, as well as the use of pressure-relieving boots. Observations found the resident in bed without heels floated and the boots not in use, despite being present in the room. Staff interviews indicated that information about the need for these interventions was available in the care plan and Kardex, but the interventions were not consistently implemented. The facility's own policy committed to the prevention of avoidable pressure injuries and the promotion of healing for existing injuries. However, the lack of adherence to physician orders and care plans for pressure ulcer prevention devices resulted in a failure to provide appropriate care for residents at risk, as evidenced by direct observations and staff statements.