Failure to Follow Pressure Ulcer Treatment Orders and Offloading Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer treatments and services to promote healing and prevent further breakdown for one cognitively intact resident with multiple pressure injuries. The resident had diagnoses including paranoid schizophrenia, anxiety disorder, and benign prostatic hyperplasia, and was readmitted with intact skin. A Braden Scale score was initially documented as 16 (mild risk) and later recalculated to 13 (moderate risk). The care plan identified the resident as having pressure ulcers and being at risk for skin impairment due to immobility and incontinence, with interventions such as frequent repositioning, keeping the resident clean and dry, use of a low air loss mattress and gel cushion, daily skin checks, and treatments as ordered. However, the care plan did not include an intervention to keep the resident’s heels floated at all times, despite the presence of a left heel pressure injury and a physician order to float the heels. Wound documentation dated 2/24/26 showed three open pressure injuries: an unstageable sacral wound measuring 11 cm by 9.5 cm, a right gluteal pressure ulcer measuring 2.5 cm by 0.8 cm, and a left heel pressure ulcer measuring 3.3 cm by 5.5 cm. Physician orders dated 2/20/26 directed wound care to the buttocks with barrier cream every shift and as needed, and for the left heel to apply skin prep daily and float the heels at all times. Facility policy required use of the wound product selection guide, a physician order for all wound treatments, interventions to reduce pressure such as offloading heels and repositioning, and that all dressings be dated and initialed by the nurse applying the dressing. Multiple observations over several days showed the resident lying on his/her back in bed with heels resting directly on the mattress and no elevation or heel protectors, despite the order to float heels at all times. On one observation, the resident’s head of bed was elevated and the resident had slid down with the head wedged between the mattress and bedrail, and heels still on the mattress. On another observation, a sacral dressing extending down both buttocks was noted with brownish discoloration at the inner edges and dated two days prior; the CNA present was unaware of the drainage and unaware of any special wound instructions beyond keeping the resident clean and dry. The DON confirmed the sacral dressing date and stated she expected staff to follow physician orders and float heels even with an air loss mattress, and the Unit Manager also stated she expected staff to ensure heels were elevated off the surface. The wound nurse reported that both she and floor nurses were responsible for wound care and that wound care tasks could be passed between shifts, indicating shared responsibility for treatments that were not consistently carried out as ordered.
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