Failure to Follow Physician Orders for Pressure Injury Prevention
Penalty
Summary
The facility failed to follow physician orders for the prevention of skin breakdown for one resident who was at risk for pressure ulcers. The resident, who was severely cognitively impaired, totally dependent on staff for care, and always incontinent of urine and bowel, had a care plan and physician orders in place to address their risk for pressure injuries. These included daily application of a foam dressing with protective cream to the coccyx area and repositioning every two hours using a wedge pillow. However, during observations, the resident was repeatedly found lying on their back without the prescribed foam dressing in place, and the wedge pillow intended for repositioning was consistently found on a bedside chair rather than being used for the resident. Interviews with nursing staff confirmed that the foam dressing was not applied as ordered and that the wedge pillow was not being used for repositioning, despite the presence of a physician's order and facility policy requiring evidence-based interventions for pressure injury prevention. The resident was observed to have a significant reddened area on the coccyx, and staff acknowledged the lack of adherence to the prescribed interventions. Facility policy review further supported that such interventions should have been implemented for residents at risk for pressure injuries.