Failure to Implement Ordered Pressure Ulcer Prevention Devices
Penalty
Summary
Surveyors identified a deficiency in pressure ulcer prevention when a resident with Alzheimer’s disease, diabetes mellitus, COPD, schizophrenia, and peripheral vascular disease, who had a history of a right heel pressure ulcer and was care planned as at risk for additional skin breakdown due to immobility, was not provided ordered pressure-relieving devices. The resident’s quarterly MDS showed moderately impaired cognition with a BIMS score of 08 and a need for assistance with self-care and mobility. Physician orders dated 09/17/24 directed that the resident wear Prevalon boots on both feet at all times except during hygiene care. However, during random observations over two days, from the morning of 01/07/26 through the evening of 01/08/26, the resident was repeatedly observed without the Prevalon boots in place, and an RN confirmed the resident had not been wearing the boots that day and did not have them on at the start of his shift. This failure to implement the ordered pressure ulcer preventative intervention constituted the cited deficiency, which was investigated under multiple complaint numbers.
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