Failure to Implement Physician-Ordered Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent the deterioration of a pressure ulcer for a resident with multiple comorbidities, including diabetes, Parkinson's disease, and dementia. The resident was admitted with a history of pressure ulcer risk and was found to have a deep tissue injury (DTI) on the left ankle. Physician orders were in place for the use of prophylactic booties while in bed to prevent further skin breakdown, as well as topical treatments. However, repeated observations by surveyors revealed that the resident was not wearing the prescribed booties while in bed, and the booties were often found on a chair at the foot of the bed instead of on the resident. The resident reported pain and was aware that the booties should be worn, but stated that staff did not always remember to apply them. There was also visible evidence of wound drainage on the bed linens, and the resident's wound was observed to have deteriorated from a DTI to an open wound with swelling, redness, and severe pain. Interviews with nursing staff and review of documentation revealed that the physician's order for booties was not included in the CNA care Kardex or the Point of Care (POC) documentation, which are used to communicate care needs to direct care staff. Both the nurse and the wound care nurse acknowledged that the omission of this intervention from the Kardex and POC meant that CNAs were not consistently aware of the need to apply the booties. The wound care nurse also indicated that the wound had worsened and that she should have been notified sooner about changes in the wound's condition. There was no documentation of the resident refusing care, and staff confirmed that the booties should have been applied as ordered. Medical record review showed that the resident's wound was initially intact but later became scabbed and then open, with no evidence that changes in the wound's condition were reported to the physician or wound care nurse in a timely manner. The resident required substantial assistance for bed mobility and dressing, further emphasizing the need for staff to ensure interventions were implemented. The lack of communication and documentation regarding the booties, as well as the failure to consistently apply them as ordered, directly contributed to the deterioration of the resident's pressure ulcer.