Failure to Implement Physician-Ordered Pressure Ulcer Interventions
Penalty
Summary
The facility failed to provide physician-ordered interventions for a resident with a history of diabetes mellitus, Parkinson's disease, localized edema, and a pressure-induced deep tissue injury on the left heel. The resident was identified as high risk for pressure ulcers and had specific physician orders for wound care, including the use of a collagen dressing, Hydrofera Blue foam dressing, and an air overlay mattress to relieve pressure. Despite these orders, staff did not apply the required air overlay device to the resident's bed, as confirmed by both nursing and administrative staff. Additionally, staff did not consistently document wound measurements or characteristics during weekly skin checks, and there was a lack of enhanced barrier precautions during wound care. The resident's care plan also included nutritional interventions to support wound healing, but the primary deficiency centered on the failure to implement the ordered pressure relief interventions. Observations revealed that the resident's left heel wound had reopened, with visible swelling and discoloration of the foot, and the wound was not measured as required. Interviews with staff confirmed that the air overlay mattress was not in place and that wound assessments were incomplete. The administrative nurse acknowledged the absence of the air overlay device and the lack of proper documentation and care plan updates. The facility was unable to provide a policy on pressure ulcer prevention and treatment when requested by surveyors.