Failure to Follow Physician Orders for Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to follow physician's orders for pressure ulcer treatment and prevention for one resident with a history of cellulitis and sepsis. The resident was observed multiple times with only one foam boot applied to the left foot, despite a physician's order for foam boots on both feet every shift to address a deep tissue injury. Additionally, the resident's treatment administration record indicated that a wound dressing change was not conducted on a specified date, as required by the physician's order for daily wound care. Interviews with staff confirmed that wound treatments should not be missed and that foam boots are necessary to prevent further injury, but documentation and observations showed these interventions were not consistently implemented. The care plan for the resident included interventions such as administering treatments as ordered and applying foam boots as tolerated. However, repeated observations showed non-compliance with these interventions, and staff interviews acknowledged the importance of adhering to physician orders for wound care and prevention. Facility policies required accurate and timely documentation of treatments and implementation of physician orders, but these were not followed, as evidenced by the missed dressing change and inconsistent use of foam boots.