State Findings:
Based on clinical record review, observations, staff interviews, and policies and procedures, the facility failed to ensure that one resident (#162) received the necessary care to prevent and to promote the healing of pressure ulcers. The sample size was 3 residents. The deficient practice could result in formation or worsening of pressure ulcers.
Review of the potential for pressure ulcer care plan initiated on February 5, 2022 revealed a left heel pressure ulcer and interventions that stated to float heels, assistance to turn/reposition, and pressure reducing mattress for skin integrity. Review of physician’s orders revealed an order dated May 12, 2022 for the resident to be in Geri chair as tolerated to promote functional body position 2 hours as tolerated one time a day.
Review of the task form for turning/repositioning revealed no evidence that repositioning had been done for 37 shifts in April 2022 and 79 shifts for May 2022.
On June 29, 2022 at 10:00 AM, upon entering the room with the wound care nurse (WCC/staff #142), the resident was observed to be lying on back with a flat pillow under both calves, the left heel had direct contact with the mattress, and no PRAFO boots were applied to either foot. The wound nurse stated that usually they roll the pillow and place it under the resident’s ankles to ensure the heel is not touching the bed. She stated that at this time the left heel was touching the mattress, and that this was not appropriate. She also stated that the resident’s left heel has a deep tissue injury that was identified on June 15, 2022 and interventions included a LALM, the RNA placing PRAFO boots daily and floating the heels off the mattress.
After the wound care observation at 10:24 AM, the spouse who is the resident’s roommate stated that the spouse has never seen staff change the resident position.
An interview was conducted on June 30, 2022 at 10:46 AM with the Director of Nursing (DON/staff #165), who reviewed the medical record and stated that the PRAFO application had not been documented on June 29, 2022. She further stated that there was no documentation in the medical record that this had been completed.
The DON reviewed the medical record and stated that there were days during June that turning
and repositioning was not documented as being completed each shift. She further stated that this did not follow the facility policy.
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