Failure to Implement Pressure-Relieving Device for Pressure Ulcer Prevention
Penalty
Summary
A resident with severe cognitive impairment, hemiplegia, aphasia, and Parkinson's Disease was identified as being at risk for pressure ulcers and required extensive assistance with activities of daily living, including bed mobility and repositioning. The resident's care plan and treatment administration record specified the use of Prevalon boots while in bed to prevent skin breakdown. Observations on two separate occasions revealed that the resident was in bed without the prescribed Prevalon boots, which were instead found on a bedside table across the room. Nursing assistants did not apply the boots during care, stating they believed the boots were only required at night. Interviews with nursing staff and the DON confirmed that the resident was at risk for pressure ulcers and that the expectation was for the Prevalon boots to be applied whenever the resident was in bed, as outlined in the care plan. Facility policy required necessary treatment and services to prevent new pressure ulcers, but staff failed to implement the prescribed pressure-relieving device as directed, resulting in a deficiency in pressure ulcer prevention care.