Failure to Consistently Apply Ordered Heel Protectors for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when a resident with a history of spinal cord injury, morbid obesity, quadriplegia, and a rare brain malformation was not provided with bilateral heel protectors as ordered by the physician. The resident had developed unstageable pressure injuries on both heels, and physician orders specified that heel protectors should be worn at all times, except during showers and activities of daily living, and replaced every 12 hours. Review of the Treatment Administration Record (TAR) showed that the heel protectors were only documented as being in place during two specific 12-hour periods, with no evidence of their use at other required times. The Director of Nursing confirmed that the heel protectors were not consistently applied as ordered, and documentation did not support that the resident received the prescribed pressure ulcer prevention measures. This lapse in following physician orders for pressure injury care was identified through record review and staff interview, and it affected a resident with significant risk factors for pressure injuries.