Failure to Maintain Clean Pressure-Reducing Devices for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that pressure-reducing devices, specifically heel-elevating boots, were free from soil for a resident with significant medical conditions, including acute respiratory failure, diabetes, severe malnutrition, sepsis, and a stage 2 pressure ulcer on the left heel. The resident's care plan included the use of air mattress and boots on both feet to prevent further skin breakdown, with regular wound care and monitoring. Despite these interventions, observations during wound care revealed that both boots had visible staining on the exterior bottom portion, with ring-like formations and pink discoloration, as well as shadowing or discoloration inside the right boot. The dressing on the resident's left heel was saturated with pale yellow drainage, but there was no evidence of seepage into the boot at that time. Subsequent observations confirmed that the boots remained soiled over multiple shifts, and interviews with nursing staff and the DON acknowledged the presence of staining and the need for new or laundered boots. The failure to maintain clean pressure-reducing devices was directly observed and confirmed by staff, affecting the resident who was dependent on staff for hygiene and at high risk for skin impairment.