Failure to Apply Ordered Heel Protectors for Pressure Ulcer Prevention
Penalty
Summary
A resident with a history of deep tissue injury to both heels was admitted to the facility and had a physician's order, as well as a care plan directive, for bilateral heel protectors to be applied while in bed. The resident was cognitively intact and dependent on staff for lower body footwear. Review of the electronic Medication Administration Record for the relevant month showed no documented evidence that heel protectors were applied as ordered. Multiple observations over several days revealed the resident lying in bed without heel protectors, with the devices found on a shelf in the room instead. The resident confirmed in interviews that staff had not been applying the heel protectors. The DON also acknowledged that the resident should have had the heel protectors on as ordered. There was no documentation or evidence provided by the facility to show that the physician's order and care plan were followed.