Failure to Provide Pressure Ulcer Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three residents. For one resident with a stage three sacral pressure ulcer and high risk for further skin breakdown, staff did not apply bilateral cushion boots as ordered by the physician while the resident was in bed. The boots, intended to protect the heels from pressure injuries, were observed unused in a plastic bag, and both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that staff should have ensured the boots were applied per the physician's order. Another resident with a history of pressure-induced deep tissue injuries (DTI) to the sacral region and left heel did not have a physician's order prior to the application of a wound dressing on the right heel. Additionally, the wound treatment for the left heel DTI was not followed as specified in the physician's order, and the type of dressing used was not specified in the order. The treatment nurse acknowledged that orders should have been clarified and obtained before applying any wound dressing, including for preventative measures, and that failure to do so could result in improper care. A third resident with a stage three sacral coccyx pressure ulcer received wound treatment without a physician's order on a specific date. The treatment nurse applied a dressing after zinc oxide ointment had already been applied, which was not included in the physician's order. The nurse admitted that the order should have been clarified before proceeding with the treatment. Facility policies reviewed indicated that wound care orders should specify the treatment, frequency, and type of dressing, and that all wound care should be performed according to physician orders and protocols.