Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
A deficiency was identified when the facility failed to implement appropriate interventions to prevent pressure ulcers for one resident. The facility's policy requires early identification of at-risk residents and the use of preventative strategies. The resident in question had a history of stroke with resulting hemiplegia, aphasia, dysphagia, and diabetes, and was completely dependent on staff for all activities of daily living, including bed mobility and toileting. The resident was assessed as being at risk for developing pressure ulcers, and a wound consult specifically recommended floating the resident's heels with pillows while in bed to prevent skin breakdown. Despite these recommendations, both clinical record review and direct observation during the survey revealed that the resident's heels were not protected or off-loaded as directed by the wound healing specialist. This lack of preventative measures was confirmed by the DON during the survey. The facility did not have the required interventions in place to protect the resident's heels, resulting in noncompliance with resident care policies and nursing service regulations.