Failure to Ensure Accurate Implementation and Documentation of Pressure Ulcer Prevention Orders
Penalty
Summary
A deficiency was identified when a resident with a history of chronic kidney disease and hyperlipidemia, who previously had a stage 3 pressure wound on the right heel, was observed multiple times not wearing prevalon boots as ordered by the physician. Instead, the resident was seen sitting in a wheelchair wearing sneakers during several observations. The physician's order and care plan both specified that prevalon boots were to be worn at all times to promote healing and prevent further skin breakdown. Despite these orders, the Medication Administration Record (MAR) indicated that staff documented the resident as having the prevalon boots on during all shifts, which was inconsistent with direct observations. The care plan also included an approach for the resident to wear prevalon boots at all times, and this was based on a physician's recommendation following a foot and ankle consult. There was no documentation in the clinical record prior to the removal of the order and care plan approach that the resident or family had requested the use of sneakers instead of the boots. The deficiency was further supported by a nursing progress note written after the observations, which stated that the resident's heel wound had healed and that the family had provided shoes for the resident to wear. However, the physician's order and care plan were not updated at the time the family made this request, and staff continued to document that the boots were in use when they were not. The facility administrator confirmed that he would have expected staff to accurately document the use of the boots and to update the physician's order and care plan in response to the family's request.
Plan Of Correction
Preparation and submission of this plan of correction does not constitute and admission of, or agreement with, it is required by State and Federal Law. It is executed and executed and implemented as a means to continuously improve the quality of care to comply with the state and federal requirements. 1. Resident 47 had no ill effects from the cited past deficient practice. During the survey, Attending Physician was contacted for clarification, order was obtained to discontinue prevalon boots, care plan was updated. 2. To identify others with the likelihood to be affected, the DON/designee completed a house-wide audit of care plans/orders to identify all residents ordered prevalon boots. Assessments were completed on all the Residents identified, need for prevalon boot was reviewed with MD, and care plan was updated with any further recommendations received. 3. To prevent a future reoccurrence, the DON/designee will educate all nursing staff to ensure documentation completed for a Resident reflects the plan of care observed in place. 4. To monitor and maintain ongoing compliance, the DON/designee will audit 5 random residents with a care plan approach for prevalon boots observing that documentation completed reflects the plan of care visualized in place, weekly x 4 and then monthly x 2. Any inaccurate findings will be corrected immediately, and findings will be reported to the QA committee monthly, for any further necessary recommendations.