Incomplete Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that physician orders for pressure ulcer care contained sufficient information to provide adequate care for a resident with multiple complex wounds. The resident, who had a history of right leg amputation, stage four sacral pressure ulcer, diabetes, and other comorbidities, was dependent on staff for activities of daily living and had cognitive impairment. Upon review, the physician orders for wound care lacked complete and specific instructions, and recommendations from the wound care nurse practitioner for nutritional supplements and vitamins to aid wound healing were not transcribed into the physician orders. Additionally, the assessment did not document the use of pressure-reducing devices or repositioning interventions at admission. Observations confirmed the resident had a low air loss mattress and pressure-reducing cushion in use, and was positioned appropriately. However, the Director of Nursing acknowledged that the wound care orders were incomplete and inadequate for the resident's needs. The facility was unable to provide a policy for wound care orders and treatment, further contributing to the deficiency in ensuring proper pressure ulcer care and prevention.