Failure to Accurately Implement Wound Care Orders and Air Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that wound care orders for a resident with a history of pressure ulcers were accurately entered into the electronic health record and that wound care was provided according to those orders. The resident, who had significant cognitive impairment and limited mobility, had a stage 4 pressure ulcer on the left hip. Medical record review showed inconsistencies in the documentation and implementation of wound care orders, including discrepancies in the frequency of dressing changes and missing documentation for several scheduled dressing changes. Orders from the wound specialist were sometimes entered incorrectly, such as being documented as every other day instead of daily, and there were instances where the site of the wound was not specified in the order. Additionally, the facility failed to maintain proper settings and documentation for the resident's bariatric air mattress, which was part of the care plan to prevent further pressure ulcers. The air mattress was observed to be set at 350 lbs, while the resident's weight ranged from 153 to 171 lbs, and staff were unaware of the correct setting. There was also a lack of a current physician order for the air mattress and no documentation that staff were checking the mattress for placement and function every shift as required by the care plan. The previous order for the mattress had been discontinued and not renewed upon the resident's re-admission. Interviews with nursing staff and the DON revealed confusion and lapses in the process for entering and verifying wound care orders and for ensuring the air mattress was set and checked appropriately. Staff acknowledged that errors had occurred in entering orders into the electronic health record and that documentation for required interventions was missing or incomplete. These failures resulted in the facility not providing pressure ulcer care and prevention measures as ordered and documented in the resident's care plan.