Failure to Provide Pressure Ulcer Prevention as Ordered
Penalty
Summary
A resident with multiple complex medical conditions, including nontraumatic intracranial hemorrhage, dysphagia, tracheostomy status, acute and chronic respiratory failure, hypertension, and gastrostomy, was admitted to the facility. Physician orders directed that Prevalon boots be applied to the resident during both day and night shifts to offload pressure and reduce the risk of skin injuries. Despite these orders, nursing notes documented the development of an open area on the resident's right posterior lower leg above the ankle, with specific wound measurements provided. On subsequent observations, the resident was not wearing the prescribed Prevalon boots. Interviews with nurse aides confirmed that the resident was not using the boots, which allowed the resident to cross his legs, resulting in a wound at the site where the legs met. The aides also noted that a blister had formed and subsequently ruptured in the same area. The Director of Nursing was informed of these findings. The failure to ensure the resident consistently received care as ordered to prevent pressure ulcers constituted the deficiency.
Plan Of Correction
1. Identified resident had their pressure relieving devices immediately applied. 2. Audit of all residents with orders for pressure relieving devices to the heels to ensure device in place. 3. Random weekly x 4 then monthly x 3 audits by DON or designee of pressure wound prevention devices for the heels to ensure compliance with interventions/orders. CNA staff educated on pressure wound prevention devices for the heels. 4. Results of the audits will be reported to the QAPI committee.