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JOHN HEINZ INSTITUTE OF REHABILITATION MEDICINE
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a patient's pressure relieving heel protectors were applied for one of one medical records reviewed (MR1).
Findings include:
Review on May 25, 2017, of the facility policy, "Wound and Skin Care/Braden Scale," dated last revised April 2014, revealed "I. Purpose: To provide a guide for the utilization of a validated risk assessment tool to identify patient at risk for the development of pressure ulcers and direct interventions to reduce risks. II. Procedure: All patients will be assessed on admission for pressure ulcer risk using the Braden Scale. Patient with a score of 18 or less will be identified at risk and will require the implementation of risk reduction strategies. Minimal preventative measures to be initiated for a Braden of 18 or less: a. Repositioning every 2 hours while in bed. b. Reinforce weight shifting in wheelchair every 15 minutes and as needed. c. Heel protectors while in bed. d. Elevate heels while in bed unless restricted. ... "
Review on May 25, 2017, of MR1 revealed the patient was admitted on April 5, 2017. There was nursing documentation the patient's heels were intact upon admission. The patient's Braden Scale Score was 18 upon admission. Nursing documentation revealed the patient developed a blister on the right heel on April 11, 2017.
Interview with EMP3 confirmed there was nursing documentation the patient developed a blister on the right heel on April 11, 2017.
Further review of MR1 revealed a physician order dated April 12, 2017, for heel protectors and to elevate the patient's heels. There was no nursing documentation for the application of the heel protectors or the elevation of the heels on April 13, 2017 and April 16, 2017.
Interview with EMP3 confirmed there was a physician order dated April 12, 2017, for heel protectors and to elevate the patient's heels. EMP3 confirmed there was no nursing documentation for the application of the heel protectors or the elevation of the patient's heels on April 13, 2017 and April 16, 2017.