Failure to Ensure Use of Ordered Pressure Reducing Devices
Penalty
Summary
The facility failed to ensure that pressure reducing devices were in place as ordered for a resident at risk for skin breakdown. The resident, who had multiple diagnoses including cerebral atherosclerosis, dementia, and moderate protein calorie malnutrition, was cognitively intact and had no active wounds. Physician orders required the use of bilateral heel protectors when in bed for wound prevention. The care plan noted the resident sometimes refused preventative boots and floating heels, but there was no documentation of refusal in the behavior logs for the period reviewed. The Treatment Administration Record (TAR) indicated the boots were in place as ordered, but direct observations on multiple occasions showed the resident either had only one boot on, had no boots on, or was not offloading his heels as required. Interviews with staff revealed that Certified Nursing Aides did not document refusals and would report them to a nurse, who was responsible for documentation. However, the nurse confirmed that documentation was completed without verifying whether the boots were actually in use, and that no refusals were documented in the behavior logs. The facility's wound management policy required timely recognition and intervention for impaired skin integrity, but the lack of accurate documentation and failure to ensure the use of ordered pressure reducing devices constituted a deficiency in care.