Failure to Implement Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to implement physician orders for pressure ulcer care for a resident with multiple stage 4 pressure ulcers and a history of paraplegia and amputation. The resident was identified as high risk for skin breakdown and had an active care plan and physician orders for regular wound assessments, skin checks, and specific wound treatments, including antibiotics and topical medications. Despite these orders and ongoing recommendations from the wound physician and nurse practitioner, the facility did not ensure that updated treatment orders were implemented after previous orders were discontinued. Documentation showed that the wound physician and nurse practitioner recommended continued antibiotic therapy and specific wound care treatments due to signs of infection, including increased drainage and odor from the sacral wound. However, after the discontinuation of prior orders, there was no evidence in the medical record that new treatment orders were put in place or carried out as recommended. Nursing staff confirmed that the wound physician's recommendations were not implemented, and the director of nursing was unaware that the necessary orders had not been established. Interviews with staff revealed that the expectation was for wound care recommendations to be implemented immediately, but this did not occur. The nurse practitioner and wound physician both stated that they expected the recommended treatments to be ordered and provided, but the documentation and staff interviews confirmed that the orders were not in place or followed for the resident's sacral wound after the previous orders ended.