Failure to Implement and Document Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to provide care consistent with professional standards to treat and prevent pressure ulcers for two residents. For one resident with osteomyelitis of the left ankle and foot and diabetes, the wound team recommended the use of pressure off-loading boots, but there was no physician order for the boots, no documentation of their use, and the care plan did not include their use. Observation showed the resident in a wheelchair with the boots beside the bed, and the resident reported that staff only occasionally applied the boots at night. The Director of Nursing confirmed that a physician order and care plan revision should have occurred after the wound team’s recommendation, but these steps were not taken. Similarly, another resident with osteomyelitis and a pressure ulcer of the sacral region had a wound team recommendation to float heels in bed, but there was no physician order for off-loading boots, no documentation of their use, and the care plan did not address their use. Observation found the resident in bed with the boots beside the bed, and the DON confirmed that the necessary physician order and care plan revision were not completed after the wound team’s recommendation. In both cases, the facility failed to document or implement recommended interventions for pressure ulcer prevention and care.