Failure to Implement and Update Wound Prevention Interventions for High-Risk Resident
Penalty
Summary
Surveyors identified a failure to implement ordered wound prevention interventions and to update the care plan for a resident with multiple comorbidities and high risk for skin breakdown. On several observations during the same day, the resident was seen lying on his back on an air mattress with his head elevated, with a foot cradle at the end of the bed, but his feet were directly on the mattress. At various times, his blankets covered one or both feet, and he wore a nonskid sock on the right foot, rather than having his heels elevated or protected as ordered. The foot cradle was in place only to keep blankets off the feet, and there was no evidence that pillows or moon boots were being used to offload the heels while he was in bed. Record review showed the resident had significant diagnoses including permanent atrial fibrillation, pulmonary fibrosis, type II DM with neuropathy, CHF, CKD, PVD, malnutrition, post-polio syndrome, and chronic pain. Physician orders included bilateral heel elevation off the bed with pillows every shift, Aquaphor to bilateral legs/feet twice daily, Pro-heal twice daily, and encouragement of moon boots at all times except for bathing and care. Additional orders were in place for daily wound care to multiple toes on the right foot. The MDS and Braden Scale documented that he was severely cognitively impaired, dependent for mobility and ADLs, at risk for pressure ulcers, and using pressure-reducing devices. A nurse’s note documented new areas on the toes discovered by a CNA during a shower, with wound measurements and treatment initiated. The resident’s care plan for increased risk of impaired skin integrity, revised earlier, included offloading heels at all times in bed, frequent repositioning, good pericare, barrier cream, and use of a pressure-reducing mattress. Later care plans were added for arterial/ischemic ulcers of the right great toe, right second toe distal, and right third toe proximal, with interventions such as daily foot inspection, keeping feet clean and dry, and wound observation and documentation. However, interviews with staff revealed that wound prevention interventions were understood to include moon boots, foot cradle, air mattress, and repositioning, but the resident was observed without heels offloaded and without moon boots in use. The DON stated the resident sometimes refused moon boots and that care plans were in the process of being updated. The ADON indicated CNAs followed printed CNA sheets rather than the electronic care plan, and the CNA sheets for this resident listed a “foot buddy to end of bed” but did not include heel offloading or moon boots, demonstrating that the resident’s wound prevention interventions were not fully implemented or reflected on the CNA task sheets.
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