Failure to Follow Care Plan and Professional Standards for Resident with Foot Wound
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including dementia, diabetes, chronic pain, and a history of skin breakdown, did not receive care in accordance with professional standards and her person-centered care plan. The resident developed a blister on the back of her left heel, which was later identified as a pressure ulcer. Despite clear instructions and care plan interventions to offload the heel and avoid pressure, an agency CNA placed tennis shoes on the resident after being told not to do so. This action was observed by the resident's family, who had previously communicated with facility staff, including the ADON and LVN, about the need to avoid tennis shoes due to the pressure area. The care plan for the resident included specific interventions such as offloading the heels with cushions or pillows, using a heel boot at all times, and changing dressings as ordered. Physician orders also specified wound care procedures and the use of a heel boot to prevent further pressure. However, there was a breakdown in communication among staff, as the CNA who put the shoes on the resident was not aware of the restriction, and there was no documented in-service training for staff regarding this specific care need. The wound care nurse acknowledged that an order should have been in place to restrict footwear to socks or open-back house shoes, but this was not implemented in a timely manner. Interviews with facility staff, including the Wound Care Nurse, ADON, and DON, revealed that while the issue of inappropriate footwear was discussed among leadership and with the family, the information was not effectively communicated to all direct care staff. The facility's in-service records did not reflect any training or instruction regarding the resident's footwear restriction during the relevant period. As a result, the resident was exposed to unnecessary discomfort and risk of worsening her foot wound due to the failure to follow the care plan and professional standards of practice.