Failure to Implement Ordered Pressure Ulcer Prevention and Offloading Measures
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention interventions for residents identified as at risk. One resident with severe cognitive impairment, right-sided paralysis, diabetes, and a brain tumor was care planned to have heels floated with a pillow and to be turned and repositioned every two to three hours and as needed, and had provider orders for weekly skin inspections and an air mattress to prevent skin breakdown. Progress notes documented that this resident could only make slight body position changes and had friction and shear identified as a potential problem, but the care plan did not include precautions for friction and shear despite this documented risk. Hospice notes described poor skin turgor and anasarca, and the resident’s family reported that staff’s method of turning consisted of placing a towel under the shoulder, which hospice staff considered inadequate, while an employee stated a towel alone could not properly position a resident and that pillows should be used. Another resident, admitted with intact cognition but at risk for pressure ulcers, had diagnoses including malnutrition, pneumonia, and respiratory failure, and was ordered to receive TED hose daily and ACE wraps in the morning and off at bedtime for edema management, along with a care plan for turning, repositioning, and offloading every two to three hours and as needed. Provider documentation noted significant lower extremity edema and weight gain related to fluid retention. During an extended observation period, this resident remained on her back with the head of the bed elevated, feet resting directly on a pillow, and another pillow placed on top of her feet, which she described as feeling heavy. At that time, she was not wearing the ordered TED hose or ACE wraps, her socks were leaving indentations in her swollen feet, and her heels were on the pillow rather than floated off the bed. The nurse acknowledged the resident’s edema, the risk of sores from tight socks, that the heels were not properly floated, and that the resident was not wearing TED hose as ordered, and admitted having placed the pillow on the feet earlier and forgetting to remove it. The facility’s policy required implementation of appropriate preventive skin measures, including mobility, repositioning, and pressure redistribution plans, and updating the care plan to identify risks for skin breakdown.
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