Failure to Implement Pressure Injury Interventions Resulting in Worsening Wound
Penalty
Summary
A deficiency was identified when a resident with multiple sclerosis, who was non-ambulatory and at risk for pressure injuries, developed a stage 3 pressure injury on the right heel while residing in the facility. Despite physician orders and care plan interventions to float the resident's heels while in bed and to offload pressure while in a wheelchair, staff failed to implement these interventions. Observations revealed the resident was repeatedly found with both feet placed directly on the floor without any pressure-reducing device while in a wheelchair, and with heels resting directly on the mattress while in bed. The resident confirmed that staff had not provided pressure-reducing boots or elevated her heels as required. Review of the medical record showed that the pressure injury was first identified as stage 3 and subsequently worsened in size over time. Documentation indicated that the wound was not healing, with saturated dressings, increased wound size, and the presence of slough and odor. The care plan and Kardex did not include specific interventions to reduce pressure on the heel while the resident was in the wheelchair, and staff were not directed to implement pressure-relieving measures. A consultant physician had recommended and ordered a pressure-eliminating boot, but this order was not implemented, and the boot remained unused in the DON's office. Interviews with the DON and staff confirmed a lack of awareness and implementation of the required interventions. The DON admitted that the resident should have had pressure-reducing boots or similar devices and acknowledged that the care plan and Kardex were incomplete regarding pressure injury interventions. Facility policies and national guidelines require elevation of heels and use of appropriate devices to prevent and treat pressure injuries, but these standards were not followed, resulting in the worsening of the resident's pressure injury.