Failure to Implement Pressure Injury Prevention Leading to Deep Tissue Injury
Penalty
Summary
A resident with a history of fractured left hip, morbid obesity, and neuropathy was admitted to the facility without any existing pressure injuries but was identified as being at risk for developing them due to limited mobility and incontinence. The care plan specified the use of heel protective devices and off-loading of heels when in bed, and the initial skin inspection documented that green heel boots were placed on both feet. However, subsequent documentation and direct care staff records showed that these interventions were not consistently implemented or documented, and there was no evidence that the resident's heels were off-loaded or that heel protective devices were used as required. Over the course of the resident's stay, staff noted a boggy/soft spot on the left heel, which remained closed and painless initially. Despite this early sign, there was no documentation of preventive interventions being carried out. The resident eventually developed a large, closed blister on the left heel, which was later identified as a deep tissue injury (DTI). The root cause analysis indicated that the injury was due to the resident's heel rubbing on the bed, exacerbated by immobility and the use of a bed that was too small for proper positioning. Interviews and emails from a collateral contact and staff confirmed that heel boots were often not applied, and the resident's heels were observed rubbing against the bed, leading to further skin breakdown. The resident reported significant discomfort and pain from the heel wound, which interfered with rehabilitation efforts. Additional concerns were raised about improper wound care, including staff peeling back dead skin and applying socks over the open wound, which became stuck to the wound. Staff interviews confirmed lapses in documentation and implementation of ordered interventions, and the resident's care records did not reflect consistent use of off-loading boots or other preventive measures as outlined in the care plan.