Failure to Reinstate Vitamin C Order for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure necessary treatment and services were provided, consistent with professional standards of practice, to promote healing of a pressure ulcer for one resident. Facility policy on Wound Care and Pressure Ulcer Care required staff to check the physician’s order for specific wound care and medication instructions. The resident had diagnoses including a stage 3 pressure ulcer, chronic respiratory failure, and hypertension. Wound Evaluation & Management Summaries over multiple dates documented recommendations from the wound provider for a dietician consult and vitamin C 500 mg BID as part of the wound care plan. Dietitian notes from multiple weekly wound meetings documented that the resident was taking vitamin C as an intervention for wound healing. However, review of the physician’s orders showed that the order for ascorbic acid (vitamin C) 500 mg BID for wounds, which began in mid-September, was discontinued in early October when the resident went to the hospital and was never re-entered upon the resident’s return. During an interview, the DON stated that the vitamin C order was discontinued when the resident was hospitalized and was not reinstated afterward, despite the wound doctor’s continued recommendation, and acknowledged that physician recommendations were expected to be implemented.
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