Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders for a resident with a pressure ulcer (PU), as evidenced by the lack of documented care on specific dates. The resident, who was at risk for pressure injuries and had a surgical wound, was supposed to receive daily treatment as per physician orders. However, the Treatment Administration Record (TAR) and progress notes indicated that care was not performed on two specific days. Additionally, the physician's recommendations for vitamin C and sulfate supplements were not included in the resident's orders, indicating a lapse in communication and documentation. Interviews with facility staff revealed that the Licensed Practical Nurse (LPN) responsible for wound care did not consistently check the physician's progress notes for new orders, relying instead on verbal communication. The Director of Nursing (DON) confirmed that the facility had a policy requiring documentation of wound care and expected nurses to update the resident's care log with any new physician recommendations. The DON acknowledged that the care nurse did not follow through with the physician's recommendations for the resident, and there was no documentation of care on the specified dates.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. (a) What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Information related to resident #9 was gathered through a historical document review and interview process. On , the nurse contacted the physician for resident #9 who gave orders for with C and as recommended. On the physician for resident #9 assessed the areas of skin with continued healing noted. (b) How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: On , the Director of Nursing/designee completed a 14 day look audit of active residents requiring care to identify other residents having the potential to be affected to ensure: 1. Treatments were performed and documented in the clinical record in accordance with physician orders. 2. Recommendations for care, including supplemental , were communicated with the physician and implemented in accordance with physician orders. Any concerns identified were immediately addressed. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On , the Director of Nursing/designee completed re-education with the licensed nursing staff on the components of this regulation with emphasis on ensuring: 1. Treatments are performed and documented in the clinical record in accordance with physician orders. 2. Recommendations for care, including supplemental are communicated with the physician and implemented in accordance with physician orders. Newly hired licensed nursing staff will be educated on these components during orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Nursing/designee will conduct an audit of at least 5 residents requiring care 3 times weekly X 4 weeks and then weekly X 2 months to ensure: 1. Treatments are performed and documented in the clinical record in accordance with physician orders. 2. Recommendations for care, including supplemental , are communicated with the physician and implemented in accordance with physician orders. Findings of these audits will be reviewed in the QA/Risk Management meeting monthly until such time as the committee determines substantial compliance has been achieved.