Failure to Follow Physician Orders for Wound Care and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not following physician's orders for two residents. For one resident with severe protein-calorie malnutrition, a dressing was observed on the left hand during a survey, despite the physician's order for the dressing having been discontinued several weeks prior. There was no evidence in the medical record of any new wound care orders after the discontinuation, and both the LPN and the Director of Nursing Services acknowledged that the dressing should not have been in place. For another resident with a history of pressure ulcers and a diagnosis of adult failure to thrive, the physician had ordered an air mattress to be set at 100 and checked every shift. However, during multiple surveyor observations, the air mattress was found to be set at 150. Both a nursing assistant and a registered nurse confirmed the incorrect setting, and upon review of the physician's order, acknowledged the discrepancy. The Director of Nursing Services did not acknowledge that the order was not followed but stated her expectation that the order would also include comfort.