Failure to Follow Physician Orders for Pressure Injury Care
Penalty
Summary
A resident with a stage 4 pressure injury on the left hip did not receive necessary treatment and services consistent with professional standards of practice to promote healing. Physician orders specified that the resident should not be in her wheelchair for more than one hour at a time, must be repositioned every 30 minutes while in the wheelchair, and should not lay on her left hip while in bed. These orders were not incorporated into the resident's care plan or care card, and staff were not consistently aware of or following these specific instructions. Observations by the surveyor revealed that the resident remained in her wheelchair for over an hour without being repositioned, despite verbalizing discomfort. Multiple staff interviews demonstrated inconsistent knowledge of the resident's repositioning requirements, with staff referencing standard protocols or the care card, which did not reflect the individualized physician orders. Staff responses varied, with some stating repositioning should occur every two hours, others indicating twice per shift, and some unaware of the specific restrictions regarding the resident's left hip. The Director of Nursing confirmed that physician orders should be followed as written but was not aware of the specific requirements for this resident. The care plan and care card lacked updates to reflect the physician's orders, and no new interventions were added after a wound infection. The facility was unable to provide a policy regarding pressure injury care when requested by the surveyor. As a result, the resident did not receive care in accordance with physician orders and professional standards, leading to a deficiency finding.