Failure to Apply Pressure-Relieving Devices as Ordered
Penalty
Summary
A resident with diagnoses including acute respiratory failure, COPD, and a brain disorder was identified as being at risk for pressure sores and was dependent on staff for activities of daily living. The care plan included interventions to prevent skin impairment due to incontinence, such as elevating both heels off the bed with pillows and the application of Medix boots (pressure-relieving boots) at all times, as ordered by the physician. Clinical documentation indicated the presence of a pressure sore on the resident's right heel, with recommendations to float the heels using the prescribed boots. Despite these interventions and orders, multiple observations over two consecutive days revealed that the resident was lying in bed without the Medix boots in place, with both heels resting directly on the bed. The boots were seen on the floor in the resident's room during all observed periods. The DON confirmed that the boots were to be applied at all times as a pressure-relieving device. This failure to implement prescribed interventions resulted in the facility not providing necessary treatment and services to promote healing and prevent new pressure sores for the resident.