Failure to Implement Care Plan and Physician Orders for Pressure Ulcer Prevention
Penalty
Summary
A deficiency was identified regarding the facility's failure to implement care planned interventions and physician-ordered treatments for pressure ulcer prevention for one resident. The resident in question was admitted with diagnoses including cerebral infarction and hemiplegia, was severely cognitively impaired, and was dependent on staff for toileting and personal hygiene. The care plan directed staff to keep the resident's skin clean and dry, minimize exposure to moisture, provide incontinence care after each episode, and use a moisture barrier product as needed. There was also a physician's order for Calmoseptine ointment to be applied to the buttocks after each episode of incontinence. Observations on two consecutive days revealed that the resident was left in a soaked brief and clothing for several hours after being placed in a chair by the previous shift. During incontinence care, there was no evidence of barrier cream or Calmoseptine ointment on the resident's skin, and staff did not apply these products at the time of care. Interviews with CNAs indicated that the resident had not been checked or changed for several hours, despite the expectation that incontinent residents be checked and changed every two hours. CNAs also expressed confusion about who was responsible for applying Calmoseptine ointment, with some believing it was a nursing responsibility and others stating they would apply it only if it was available in the room. Further interviews with nursing staff and the Director of Nursing confirmed that Calmoseptine ointment was considered medicated, stored in the treatment cart, and should be administered by a nurse. Documentation in the Medication Administration Record indicated that the ointment had been administered, but the nurse later admitted this was not the case and that CNAs typically performed this task. There was also a lack of awareness among staff regarding the specific order for Calmoseptine ointment to be applied after each incontinence episode. These findings demonstrate a failure to follow care plan interventions and physician orders for pressure ulcer prevention.