Failure to Follow Physician's Order for Pressure Ulcer Intervention
Penalty
Summary
Staff failed to follow a physician's order for a resident with severe cognitive impairment, congestive heart failure, kidney disease, non-Alzheimer's dementia, and a right heel pressure ulcer. The physician's order and care plan both directed that Prevalon boots be applied at all times as tolerated, except when the resident was weight-bearing, to promote wound healing. Multiple observations on different occasions showed the resident was not wearing the Prevalon boots while in her wheelchair or in bed, and staff were unable to locate the boots in her room. Interviews with various staff members, including CNAs, a CMA, and an LPN, confirmed that the resident was non-weight bearing, required a mechanical lift for transfers, and had not refused care. Staff also indicated that the boots should have been on while the resident was in bed, in a wheelchair, or in a lift sling, and that there was no documentation or notification of refusal. The LPN was unaware the resident was not wearing the boots, and the DON stated the expectation was for this intervention to be included in the care plan rather than as a physician's order.