F0684

D

Failure to Follow Physician Orders for Wheelchair Seat Mapping for Pressure Ulcer Management

Grants Pass, Oregon Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders for wound care interventions for one cognitively intact resident with a Stage 4 sacral pressure ulcer and a history of stroke. The resident was evaluated in a wound ostomy clinic, where the nurse practitioner documented that the resident’s wound healing had stalled and ordered a wheelchair seat mapping to obtain an appropriate new wheelchair cushion after a previously ordered Roho cushion had been removed from use. The order specified that the facility should schedule the seat mapping appointment, and a progress note documented that the resident returned from wound care with this new order related to the sacral pressure injury. The order was faxed to a vendor the same day.

Despite this, subsequent documentation showed that the seat mapping was not timely ordered or completed. Two days after the order, the nurse practitioner confirmed that the seat mapping had still not been ordered or completed. Weeks later, a nurse’s progress note indicated that when staff called the vendor for an update, the vendor reported they needed the order faxed, and a later note documented that the vendor had not received any faxes from the facility. It was confirmed that the facility had faxed the order to an incorrect fax number. Additional information from the DNS indicated that the referral had to be re-faxed months later and that there were ongoing unsuccessful attempts at communication with the vendor, resulting in a significant delay between the original order and the scheduling of the seat mapping appointment. This sequence of events reflects the facility’s failure to ensure timely and accurate coordination and follow-through on the physician’s order for wheelchair seat mapping for the resident’s pressure ulcer management.