Failure to Implement Physician-Ordered Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement physician-ordered interventions to prevent skin breakdown for a resident with multiple risk factors, including multiple sclerosis, coronary artery disease, hypertension, major depressive disorder, metabolic encephalopathy, muscle weakness, and dementia. The resident was assessed as having moderately impaired cognition, was dependent on staff for activities of daily living, incontinent of bowel and bladder, and at moderate risk for pressure ulcer development. Physician orders included the use of a pressure-reducing cushion in the wheelchair at all times and offloading boots to both lower extremities. The care plan was updated to address these risks and included specific interventions such as the use of a Roho cushion and offloading boots. Despite these orders and care plan interventions, observations revealed that the resident was repeatedly found seated in a geri-chair without the required pressure-relieving cushion or offloading boots in place. Staff interviews confirmed that the devices were not in use and could not be located in the resident's room. Additionally, review of the CNA's electronic resident-specific information lacked instructions regarding the use of these devices. The nursing supervisor verified that the devices were ordered and not in place, and acknowledged the resident's recent history of a healed stage III pressure ulcer to the coccyx.