Failure to Implement Ordered Pressure-Relieving Interventions for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered pressure-relieving interventions were in place for a resident with existing pressure injuries and a high risk for further skin breakdown. The resident was admitted with diagnoses including sepsis, UTI, dementia, and a sacral pressure injury, and an assessment identified her as high risk for pressure injuries. Physician orders directed the use of waffle boots while in bed, and the care plan included encouraging the resident to float her heels and use an air mattress. Weekly wound assessments documented two stage 4 pressure injuries to the sacrum and indicated the use of a low air loss mattress. On the observed day, CNAs transferred the resident to bed with a sacral dressing in place and a pump attached to the bed, but the pump was not turned on and the resident’s feet were placed directly on the mattress. Over 30 minutes later, the air mattress pump remained off until a CNA attempted to turn it on, then shut it off again after hearing a loud noise, stating she did not know what was wrong and would notify maintenance. An hour later, the air mattress was still off while the resident was asleep in bed. Additionally, waffle boots ordered for use while in bed were observed on the floor beside the resident’s recliner rather than on the resident. Staff interviews described pressure injury prevention interventions such as repositioning, air mattresses, and elevating feet, and the facility’s wound care policy stated that evidence-based treatments would be provided in accordance with current standards of practice and physician orders.
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