Failure to Follow Pressure Ulcer Prevention and Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received necessary services to prevent and treat pressure ulcers in accordance with physician orders and facility policy. For one resident with quadriplegia, high blood pressure, and a neurogenic bladder, surveyors observed the resident in bed on multiple occasions wearing Prafo boots and later reported use of bunny boots according to a schedule the resident described (Prafo boots in the morning while in bed and bunny boots starting at 5:00 p.m.). However, review of the clinical record and physician orders showed no documented orders or schedule for either the Prafo or bunny boots. A registered nurse confirmed that there were no current physician orders or schedules for these devices, despite their ongoing use. For another resident with high blood pressure, malnutrition, and heart failure, the clinical record contained a physician’s order to wash the coccyx and peri/groin area twice daily with soap and water and apply a zinc-based barrier cream, with instructions to report any decline in wound condition. Review of the Treatment Administration Record showed that this ordered treatment was not provided on one evening shift. The DON confirmed that the ordered pressure ulcer prevention treatment was not administered as prescribed and further acknowledged that the facility failed to ensure residents were monitored, assessed, and received necessary services to prevent pressure ulcers or wounds from developing for two of three residents reviewed.
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