Failure to Implement Physician Orders for Pressure Injury Prevention and Care
Penalty
Summary
Surveyors identified that the facility failed to provide necessary treatment and services to prevent and promote healing of pressure injuries for two residents. One resident, who had severe protein-calorie malnutrition, traumatic brain injury, dementia, and was receiving hospice care, had physician orders for Prevalon boots to be worn at all times while in bed due to bilateral heel pressure injuries. However, observations revealed the resident was in bed without the boots, and staff were unaware of the order. The care plan and care card did not reflect the order for Prevalon boots, and the boots were not initially found in the resident's room. Only after inquiry did staff locate and apply the boots, and the Director of Nursing acknowledged the care plan needed updating to include this intervention. Another resident, with vascular dementia, cerebral atherosclerosis, and an unstageable pressure injury on the coccyx, had a physician order to be laid down after all meals. Despite this, the resident was repeatedly observed in a broda chair in common areas after meals, contrary to the order. The wound was noted to be improving, but the facility leadership acknowledged the concern when it was brought to their attention. These findings demonstrate that the facility did not ensure physician orders related to pressure injury prevention and care were consistently implemented for residents at risk.