Failure to Consistently Implement Heel-Floating Intervention for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when a resident with dementia, high blood pressure, and peripheral vascular disease was not consistently provided with care-planned interventions to prevent pressure ulcers, as required by their care plan and physician's orders. The resident's care plan and Kardex specified that their heels should be floated while in bed to maintain skin integrity, and the Treatment Administration Record included a physician order for this intervention. Despite these directives, multiple observations over several days found the resident in bed with their heels resting directly on the mattress, rather than being floated as required. Interviews with staff revealed that while some staff attempted to reposition the resident and float their heels, the intervention was not consistently implemented. Staff noted that the resident often slid down in bed, causing their heels to rest on the mattress, and that the resident sometimes requested the pillow used for floating be removed. The LPN/Case Manager was unaware of the issue with the resident sliding down, and the DON acknowledged the need for documentation of refusals and creative preventative measures. The failure to consistently implement the heel-floating intervention as ordered constituted the deficiency.