Failure to Follow Physician Orders for Pressure Ulcer Prevention Device
Penalty
Summary
Staff failed to follow physician orders for the use of a specialized wedge device to assist with turning and repositioning a resident at risk for pressure ulcers. The resident, who had multiple diagnoses including morbid obesity, chronic kidney disease, and a stage II pressure ulcer on the right buttocks, was dependent on staff for bed mobility and personal care. Physician orders specified that the resident should be turned and repositioned using a wedge every two hours as tolerated. However, both the resident and an LPN confirmed that the wedge had been missing for several days, and staff substituted a pillow when the wedge was unavailable. Documentation showed that staff signed off on the treatment record as if the wedge was used, despite its absence. Interviews with facility leadership confirmed that staff are expected to follow orders as written and verify the presence of required equipment before documenting care. The facility was unable to provide a policy regarding adherence to physician orders.