Delay in Providing Specialty Device for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide a specialty device, darco boots, in a timely manner for a resident with pressure ulcers. The resident, who had a history of acute osteomyelitis, paraplegia, peripheral vascular disease, and type 2 diabetes with diabetic neuropathy, was observed waiting for the darco boots recommended by a wound consult physician. Despite the resident's intact cognition and ability to communicate needs, the boots were not provided promptly, leading to a deficiency in care. The delay in providing the darco boots was due to a breakdown in communication and procedure within the facility. The Director of Rehab was not informed of the prescription for the darco boots until nearly a month after it was issued, due to the prescription not being communicated by the nursing staff. The usual procedure required a nurse to notify the Director of Rehab of such prescriptions, but this did not occur. Additionally, the resident was instructed to continue using PRAFO boots until the darco boots arrived, but the delay in obtaining the correct size further prolonged the issue. The Interim Director of Nursing acknowledged procedural lapses, including the failure to verify recommendations from the wound consult and the lack of communication regarding the prescription. The facility's policy required that consult recommendations be documented and communicated to the attending physician, but this process was not followed. The prescription was scanned into the electronic system, but the Director of Rehab was unaware of it until the resident inquired about the boots, highlighting a significant gap in the facility's communication and follow-up procedures.
Plan Of Correction
1. Corrective Action of Areas Affected: Resident #14 received the [R]. 2. Other Areas Affected: The Director of Nursing/designee has conducted an initial audit for residents with orders for darco boots to validate the boots have been obtained as per orders. 3. Systemic Changes to Prevent Future Occurrences: The Director of Nursing/designee has re-educated licensed nursing staff on the process for reviewing wound consultations and verifying new orders are followed. 4. Monitoring of Corrective Action: The Director of Nursing/designee will review charts for residents with pressure injuries to validate that treatments are being completed as per order and specialty devices utilized weekly x4 weeks, then monthly x2. Results of the audit will be reported monthly at the Quality Assurance Improvement Meetings for review and recommendations.