Failure to Implement Provider-Recommended Pressure Relief for Heel Wound
Penalty
Summary
A resident with diabetes mellitus and a non-pressure related arterial ulcer on the left heel was admitted to the facility. The Wound Care Nurse Practitioner (NP) recommended the use of a soft protective boot to float the resident's left heel while in bed, as documented in a progress note. However, a review of the resident's medical record and physician orders revealed that no provider order for a protective boot was obtained or implemented. Multiple observations over several days confirmed that the resident's heels were in contact with the mattress and no protective boot was in use. Interviews with facility staff, including the Treatment Nurse, Nurse Aide, Wound Care NP, and Director of Nursing (DON), revealed a breakdown in communication and follow-through regarding the NP's recommendation. The Treatment Nurse was aware of the recommendation but did not obtain a provider order, and the DON was not aware of the recommendation for the protective boot. As a result, the recommended pressure relief measure was not provided according to the resident's care needs and provider orders.