Failure to Implement Wound Care Orders
Penalty
Summary
The facility failed to clarify and implement appropriate treatment orders for a resident with a non-healing surgical wound. According to the Pennsylvania Code, registered nurses are required to collect and analyze data to determine nursing care needs and carry out actions that promote well-being. However, the facility did not adhere to these standards. A quarterly Minimum Data Set assessment indicated that the resident was alert, oriented, and required assistance with care. A wound consult report recommended specific treatments, including the use of VASHE wound cleanser and medi-honey applied to alginate, but these were not followed as per the Treatment Administration Record. Further wound consult reports recommended soaking the wound in VASHE and applying medihoney with a biofilm dressing, but these instructions were also not followed. An interview with the Director of Nursing revealed that the Wound Nurse Practitioner wrote orders that did not align with the wound consultant's recommendations, and nursing staff failed to review the consultant's notes to ensure consistency with the orders. This discrepancy led to the facility's failure to meet professional standards of quality in providing care for the resident.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This Plan of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #2 careplan changes were completed and are accurate. Resident #25 careplan changes were completed and are accurate. Resident #41 careplan changes were completed and are accurate. Resident #64 careplan changes were completed and are accurate. Resident #79 careplan changes were completed and are accurate. Resident #106 careplan changes were completed and are accurate. Resident #130 careplan changes were completed and are accurate. To identify other residents with the potential to be affected, the Director of Nursing/designee will review care plans to ensure any changes to code status, Enhanced Barrier Precautions, antibiotics, out of bed orders, hospice care and residents on diuretic medication within the last two weeks were reviewed/revised correctly on the care plan. To prevent a future occurrence, the Director of Nursing/designee provided education to the interdisciplinary team on the comprehensive care planning policy. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to ensure any changes to orders are reflected on the care plan. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations. Resident #69 handwritten order for wound care was to cleanse the wound; order entered into the computer that was followed was to cleanse the wound. Clarification for the order was obtained at the time of the survey to "cleanse the wound". To identify other residents with the potential to be affected, the Director of Nursing/designee will review wound consult notes and handwritten orders for the last 2 weeks to ensure they match and get any clarification if needed. To prevent a future occurrence, the Director of Nursing/designee provided education to the licensed staff on ensuring progress notes from the wound Certified Registered Nurse Practitioner (CRNP), match the handwritten order and get clarification if needed. Education was also provided to the wound CRNP to ensure that his orders in his notes match his handwritten orders. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 on wound care orders and wound care progress notes to ensure accuracy and consistency. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.