Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency was identified when a resident with multiple comorbidities, including a history of cerebrovascular accident with hemiplegia, contractures, and decreased mobility, was not provided with appropriate pressure ulcer prevention interventions. The resident was assessed as being at risk for pressure ulcer formation and had a care plan in place that included interventions such as floating heels, use of heel boots, frequent turning and repositioning, and daily skin monitoring. Despite these documented interventions and physician orders, observations revealed that the resident was lying in bed with a dressing on her right ankle/foot and no off-loading devices, such as heel boots, in use. Further investigation through interviews confirmed that heel boots were available but not being applied by staff, as noted by a family member who found the boots in the resident's closet. An LPN also verified that no off-loading was provided to the pressure ulcer on the resident's right ankle. The lack of implementation of prescribed interventions for pressure ulcer prevention and care led to the deficiency, as the resident developed a stage II pressure ulcer that was being monitored and treated, but preventive measures were not consistently followed.