Failure to Provide Ordered Pressure Relief for Resident with Pressure Ulcer
Penalty
Summary
A resident with a history of acute kidney failure, muscle weakness, neuromuscular dysfunction of the bladder, and paraplegia was admitted to the facility and assessed as requiring self-care assistance. The resident's care plan included interventions for multiple pressure ulcers due to immobility, specifically the use of Prevalon boots every shift to relieve pressure on the heels and prevent further skin breakdown. The resident had an unstageable pressure ulcer on the left heel, and physician orders required the application of Prevalon boots every shift. Despite these orders, multiple observations over two days revealed that the resident was not wearing the Prevalon boots at any time. The resident confirmed that staff had not placed the boots on him for over a month. This was further corroborated by the unit manager, who acknowledged that the resident was not wearing the boots as ordered. The failure to implement the prescribed pressure relief intervention constituted a deficiency in the facility's care for residents with pressure ulcers.