Failure to Follow Physician's Orders for Pressure Injury Care
Penalty
Summary
The facility failed to adhere to a physician's order regarding the care of a resident with a pressure injury on the left heel. The resident, who was moderately dependent on assistance for lower body care, was observed wearing socks despite a specific order to allow the heel to air dry and not to wear socks. The care plan included interventions such as floating the heels while in bed and applying treatment to the heel on specific days. However, observations revealed that the resident's heels were not properly off-loaded, and heel protectors were found on the floor instead of being used as intended. Staff A, a wound care nurse, applied socks to the resident's feet after treatment, contrary to the physician's order. The resident expressed discomfort, stating that her heels hurt, yet the staff did not provide guidance or education on the risks of wearing socks over the affected area. Despite a visitor's advice to remove the socks, the resident continued to wear them until the surveyor intervened. Staff A acknowledged the oversight and the importance of following the physician's order after being reminded by the surveyor.
Plan Of Correction
Resident #100 receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent and prevent new wounds from developing. Res #100 was educated on wearing socks and agreed to follow care recommendations. Res #100 has adequate pillows to off-load heels when in bed or when heels are in a dependent position. Nursing team members will remind Res #100 to keep heels off-loaded as recommended during care and daily interactions. Care orders were audited to ensure no other residents were affected by this alleged deficient practice. Residents with similar needs were observed to ensure proper control practices were followed. No residents were affected by this alleged deficient practice. Licensed nurses will be educated to follow physician orders related to care by the Director of Education/designee. Nursing team members will be educated on proper control procedures by the Director of Education/designee. Care orders will be audited to ensure they are completed per physician orders weekly for 4 weeks and monthly for 12 months by the Director of Clinical Services/designee. Proper control procedures will be audited for control placement weekly for 4 weeks and monthly for 12 months by the Director of Clinical Services/designee. All audits will be brought to the QAPI committee monthly for review.