Failure to Ensure Correct Negative Pressure Wound Device Settings for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care and treatment consistent with professional standards for a resident with pressure ulcers, specifically regarding the use of a negative pressure wound device. The resident, an elderly female with diagnoses including heart failure, pyelonephritis, and dementia, was admitted with two stage IV pressure ulcers. Physician orders specified that the negative pressure wound device should be set to 125 mmHg. However, on two consecutive days, observations revealed the device was set at 150 mmHg instead of the ordered setting. The resident was unaware of the correct settings or when they were last changed. Interviews with nursing staff indicated a lack of clarity and oversight regarding the correct device settings. The nurse assigned to the resident was uncertain about the required settings and deferred to the treatment nurse, who then acknowledged the discrepancy and adjusted the device to the correct setting. The DON stated that it was the responsibility of the treatment nurse to ensure the settings matched physician orders and characterized incorrect settings as a medication error. Facility policy also required verification of physician orders and correct device settings, which was not followed in this instance.