Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement physician-ordered interventions to prevent pressure ulcers for three residents who were identified as being at risk. For one resident with diagnoses including congestive heart failure, atrial fibrillation, muscle weakness, and pulmonary hypertension, staff did not apply heel boots as ordered while the resident was in bed, despite the care plan identifying a risk for skin breakdown due to immobility. Another resident with vascular dementia, diabetes, heart disease, and muscle weakness, who was nonresponsive and at risk for pressure ulcers, was observed in bed without the ordered Prevalon boots. The care plan for this resident also noted a risk for skin breakdown related to immobility and medical condition. A third resident, with diabetes and muscle weakness and identified as at risk for pressure ulcers, had a physician's order to float heels while in bed. However, observation revealed that the resident's heels were directly on the bed, contrary to the order. The Director of Nursing confirmed that the protective devices and interventions were not in place for these residents as required by their care plans and physician orders.