Failure to Implement Pressure Ulcer Prevention and Wound Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention interventions for residents at risk and to follow a wound physician’s treatment orders for an existing pressure ulcer. One resident with a high Braden risk score had physician orders for protective heel boots to both feet at all times and an air mattress, and her care plan identified risk factors including impaired cognition, incontinence, impaired mobility, and impaired nutrition. During observation, her heel boots were on the bedside table, her heels were resting directly on the mattress, and her air mattress was not plugged in or functioning, with no indicator lights on. The wound LPN confirmed that the resident should always have heel protection boots on and a functioning air mattress, and later stated that interventions for this resident included an air mattress, heel boots at all times, frequent incontinence care, and frequent repositioning. Another resident with a moderate Braden risk score was observed in bed with protective heel boots present in the room but not on his feet; one boot was on the dresser and one on the floor, and his heels were directly on the mattress with slight redness noted bilaterally. This resident reported that staff sometimes put the boots on and sometimes did not, and the wound LPN stated that this resident was at risk due to immobility and that his interventions included heel boots when in bed, turning every two hours, and nutritional supplements. The facility also failed to implement the wound physician’s specific treatment orders for a resident with a sacral pressure ulcer. A specialty physician’s initial wound evaluation documented an unstageable sacral pressure ulcer with necrotic and viable tissue and ordered daily and as-needed application of sodium hypochlorite (Dakin’s) solution, silver sulfadiazine 1%, and a bordered gauze dressing. A subsequent evaluation showed the wound as a stage 3 sacral pressure ulcer that was not at goal due to infection. However, the physician’s order sheet initially contained an order to cleanse the sacrum with wound wash, pat dry, apply Silvadene to the wound bed, and cover with bordered foam daily and as needed, with no order to cleanse with Dakin’s until several days after the initial wound evaluation. The wound LPN stated that the wound nurse inputs all new physician orders into the record and that all wound physician orders should be followed, and clarified that wound wash is a gentle cleanser while Dakin’s is a bleach solution used for debridement and as an antimicrobial. The wound physician stated he orders Dakin’s when he suspects infection, described it as a strong wound cleanser, and said he expected staff to follow his orders. The facility’s own pressure ulcer and wound prevention/management policy states that residents with pressure ulcers should receive necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.
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