Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement pressure ulcer prevention measures for two residents identified as being at high risk for skin breakdown. One resident with diagnoses including Parkinson's disease, dementia, and hypertension was observed lying in bed with heels resting directly on the mattress, despite care plan interventions specifying that heels should be offloaded. Staff present at the time stated that all necessary care had been completed, and no further interventions were provided to offload the resident's heels. The resident's care plan and risk assessments documented the need for heel offloading due to high risk for pressure ulcers, but this intervention was not followed during the observation period. Another resident with severe cognitive impairment, chronic kidney disease, Alzheimer's disease, and heart failure was also observed lying in bed with heels resting on the mattress, while prescribed offloading boots were not in use and instead placed on a chair in the room. Staff provided inconsistent explanations regarding the use of offloading devices, with one CNA stating the boots were only needed in the afternoon, while another CNA clarified that offloading should occur at all times when the resident is in bed. The facility's policy and care plans required consistent offloading of heels to prevent pressure ulcers, but these measures were not implemented as observed.