Failure to Implement Pressure Ulcer Prevention Interventions as Ordered
Penalty
Summary
The facility failed to implement physician-ordered interventions for pressure ulcer prevention for a resident with multiple risk factors, including severe cognitive impairment, incontinence, contractures, and limited mobility. The resident was assessed as high risk for pressure ulcer development and had specific orders for heel offloading while in bed, weekly skin assessments, and application of barrier cream after each incontinence episode. Despite these orders, observations over two days revealed the resident was repeatedly found in bed with heels and feet resting on the mattress and pressed against the footboard, without any heel offloading devices in place. Staff interviews indicated a lack of awareness and adherence to the resident's care plan and physician orders. Certified nurse aides (CNAs) were unaware of the requirement to offload the resident's heels and did not consistently communicate care refusals or difficulties to nursing staff. One CNA did not notify the nurse when unable to provide care due to the resident's combativeness, resulting in prolonged periods without incontinence care or repositioning. When care was eventually provided, the resident was found with significant soiling and reddened skin on the buttock and left heel, indicating the development of skin issues. Further review revealed that required weekly skin assessments were not documented as completed for two consecutive weeks, contrary to physician orders and facility policy. The facility's policy mandates regular risk assessments, daily skin inspections, and timely repositioning for residents at risk of pressure ulcers. The lack of adherence to these protocols and physician orders directly contributed to the deficiency identified during the survey.