Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency was identified when a resident with diagnoses including aphasia, hypertension, severe physical limitations, and immobility was not provided with required interventions to prevent pressure ulcers. The resident was assessed as being at risk for pressure ulcers and unable to communicate needs. The care plan specified that cushioned heel boots should be applied to both feet while the resident was in bed to protect skin integrity. However, during multiple observations, the resident was found in bed without the heel boots in place and with heels not elevated. The DON confirmed that the resident should have had the heel boots on while in bed.