Failure to Prevent and Assess Pressure Ulcers Due to Inadequate Physician Orders and Wound Monitoring
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention and care for a resident with multiple risk factors, including a recent tibial fracture, Alzheimer's disease, dementia, and severe cognitive impairment. Upon admission, the resident was already at moderate risk for pressure ulcers and had an unhealed unstageable pressure ulcer on the left great toe. The resident was placed on non-weight bearing orders and had a non-removable splint applied to the left lower extremity. However, the resident repeatedly removed the splint and dressings, and the facility did not obtain timely or adequate physician orders or instructions following the removal of the non-removable brace. This led to the development of an unstageable pressure ulcer on the left heel. After the splint was removed at an orthopedic appointment, a new pressure ulcer was identified on the left heel. The facility staff replaced the non-removable splint themselves without further physician guidance, and the area was not reassessed as required. Additionally, a wound care clinic later identified a new unstageable pressure ulcer on the top of the left foot. Despite this diagnosis, the facility failed to routinely assess this wound or create a specific plan of care to address it. Weekly wound assessments were not completed for the top of the left foot wound, and the care plan was not updated to include this new pressure ulcer. Interviews with facility staff revealed that the wound on the top of the left foot was initially assessed as a scabbed area and not entered into the wound management program, resulting in a lack of routine assessments. Documentation also showed that the facility did not consistently follow up with the orthopedic physician's office after the resident removed the splint and did not document all attempts at physician notification. The facility's own policy required daily skin inspections and close monitoring when casts and splints are present, but these measures were not fully implemented for this resident.