Failure to Follow Physician Orders and Care Plans for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to follow physician's orders and care plans for two residents by not adhering to specific instructions regarding pressure ulcer prevention and management. For one resident with a history of diabetes, dementia, anemia, and moderate risk for pressure ulcers, staff did not limit the resident's sitting time in a wheelchair to one to two hours as ordered, nor did they ensure the use of a gel cushion as specified. Observations showed the resident was seated in a wheelchair for approximately three hours, and staff interviews confirmed that the required documentation for turning and repositioning was incomplete or missing for several shifts. Additionally, the resident's low air loss mattress was not set according to the resident's weight, as required by physician's orders and the care plan, with the analog pressure dial set significantly higher than the resident's actual weight. Staff interviews revealed that the lack of documentation and failure to follow orders could result in the facility being unaware if repositioning was performed, and that the incorrect mattress setting could pose a risk of falls or injury. The treatment nurse and DON both acknowledged that the mattress settings were not correct and that staff were not following the care plan interventions. The care plan for this resident included specific interventions for pressure ulcer prevention, such as limiting sitting time, using a gel cushion, and adjusting the mattress settings according to weight and height, but these were not consistently implemented. For the second resident, who had a stage four pressure ulcer, atrophy, and anemia, the facility also failed to set the low air loss mattress according to the resident's weight as ordered. Observations and interviews confirmed that the mattress was set for a much higher weight than the resident's actual weight. The care plan for this resident required the use of a pressure-relieving device and proper mattress settings, but these interventions were not followed. The DON and treatment nurse both confirmed that the settings were incorrect and that the facility was not adhering to its own policies and procedures for skin and wound management, as well as comprehensive person-centered care planning.