Failure to Implement and Document Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to provide necessary treatment and interventions to promote healing and prevent new pressure ulcers for two residents. For one resident with a left heel pressure ulcer and severe cognitive deficits, physician orders required the use of bilateral booties and offloading of the left heel while in bed. Despite these orders, the resident was repeatedly observed in bed with heels directly on the mattress and without booties, and there was no documentation of refusal or rationale for not implementing the interventions. Staff interviews revealed a lack of awareness regarding the resident's wound and misunderstanding of the physician's orders, with some staff believing the interventions were only required during the night shift. Another resident, who had a history of a heel pressure ulcer and was dependent on staff for footwear, also had a physician order for wearing Prevelon boots while in bed. This resident was observed multiple times in bed without booties and with heels on the mattress, and no booties were visible in the room. The resident reported not being offered booties for a long time and expressed willingness to wear them if provided. Staff interviews indicated a lack of awareness and incorrect assumptions about when the interventions were required, with documentation inaccurately reflecting that the interventions were implemented every shift. In both cases, the facility's documentation on the Treatment Administration Record indicated that the prescribed interventions were carried out, but direct observation and staff interviews contradicted this. There was no evidence of resident refusal or clinical justification for not following the physician's orders, and staff were not consistently aware of the residents' needs or the specifics of the orders. The facility's failure to implement and accurately document the required interventions led to the deficiency.