Failure to Implement Ordered Pressure-Relief and Wound Care Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions and physician-ordered wound care for a resident with significant skin integrity issues. The resident had chronic pain, a history of cerebral infarction with expressive aphasia, left hemiplegia, obesity, bowel incontinence, diarrhea, and moderate protein-calorie malnutrition, and was identified as having actual impairment to skin integrity. The care plan and orders included daily wound care to the right elbow, right plantar foot, and heel, as well as continuous use of a soft pillow boot on the right elbow and pressure-reducing boots to both lower extremities, along with turning and repositioning every two hours and as needed. Despite these orders and care plan interventions, surveyor observations on the same day showed the resident lying on her back in bed without the ordered pressure-reducing boots, which were instead found in a chair, and her feet resting directly on the bed without any offloading devices. Further observation during wound care revealed that when the RN removed the soft pillow from the resident’s right arm, the right elbow wound was open to air with no dressing in place, and no dislodged dressing could be found in the bed or on the floor. Interviews with staff confirmed that the resident was supposed to wear the pressure-reducing devices on the right arm and both feet at all times and that the resident tolerated these devices well. The wound care NP stated that the resident was at high risk for worsening skin breakdown and that adherence to pressure-reducing interventions was crucial. An LPN reported that CNAs were not consistently communicating when dressings became soiled or dislodged and were removed, resulting in nurses not being notified to reapply dressings. These observations and interviews demonstrate that the facility did not consistently implement the resident’s care plan interventions and wound care orders as written.
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