Failure to Implement Physician-Ordered Wound Interventions and Notify Provider
Penalty
Summary
The facility failed to follow physician orders and implement preventative wound interventions for a resident with a left heel ulcer. After a consultant assessed the resident and ordered suspension boots and daily wound cleaning, the facility did not enter the order for suspension boots into the electronic medical record (EMR), nor did they apply the boots as directed. The resident's care plan and EMR lacked documentation of the suspension boots order, and there was no evidence that the intervention was implemented. Additionally, the facility did not notify the physician when the resident's left heel wound opened, as required by the order. The resident had multiple diagnoses, including congestive heart failure, diabetes mellitus, and dementia with agitation, and was at risk for skin issues due to impaired mobility and incontinence. Over time, the resident's wound worsened, progressing from a deep tissue injury to an unstageable pressure ulcer, and eventually required advanced wound care interventions such as a wound vac. The EMR showed gaps in documentation of wound assessments, notifications to the physician and the resident's representative, and implementation of ordered interventions. The care plan also failed to address the physician's order for heel protectors and did not include all necessary interventions related to the resident's left heel wound. Interviews with staff revealed confusion and lack of clarity regarding the implementation and documentation of physician orders for wound care and preventative devices. Staff were unsure if the suspension boots were ever ordered or applied, and the EMR did not reflect the order or its implementation. The facility's policies required prompt transcription and implementation of physician orders, as well as systematic pressure injury prevention and management, but these were not followed in this case, resulting in a decline in the resident's wound status and the development of additional complications.