Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards for two residents. For one resident with a history of stage three sacral pressure ulcer, contractures, and severe cognitive impairment, there was a physician's order to apply heel protectors to both feet at all times, both in bed and in a wheelchair. Observations revealed that the resident was not wearing heel protectors, and both the CNA and LVN assigned to the resident confirmed that the heel protectors were not applied. The CNA was unaware of the order, and the LVN acknowledged responsibility for ensuring the use of pressure-relieving devices but confirmed the protectors were not in place. The RN also confirmed the order and stated that staff should have ensured the heel protectors were applied as the resident was at high risk for pressure ulcers due to fragile skin, contractures, and poor nutrition. For another resident with a stage four right gluteal pressure injury, dementia, diabetes, and severe cognitive impairment, there was a physician's order for a low air loss mattress (LALM) to be set according to the resident's current weight. The resident's weight was documented as 114 lbs, but the LALM was observed to be set at 160 lbs. The Infection Preventionist and DON both confirmed that the mattress should have been set to 120 lbs, the closest available setting to the resident's weight. The incorrect setting was not in accordance with the physician's order or the facility's care plan, which specified that the LALM should be set based on the resident's current weight to minimize the risk of skin breakdown. Facility policy and procedures required staff to review care plans, identify risk factors, and implement appropriate interventions, including the use of pressure-relieving devices and support surfaces. The operations manual for the LALM also specified that the mattress should be adjusted according to the patient's weight. Despite these guidelines, staff failed to ensure that the prescribed interventions were implemented for both residents, as evidenced by the lack of heel protectors and the incorrect LALM setting.