Failure to Clarify Provider's Orders for Wound Care
Penalty
Summary
The facility failed to clarify a provider's orders for a resident, leading to a deficiency in meeting professional standards of quality care. The resident, who was cognitively intact and required assistance for daily care needs, had a history of a left hip fracture, diabetes, and dementia. The resident's care plan included orders for wound care on the heels due to deep tissue injury and pressure ulcers. However, discrepancies were found between the verbal orders given by the wound consultant and the written orders documented in the clinical records. The verbal orders instructed the wound nurse to change the dressings every other day, while the written assessments indicated daily changes. The inconsistency in the orders was further complicated by the wound consultant's process, where verbal orders were given to the wound nurse, but the consultant's assistant typed the assessments, leading to mismatched documentation. This lack of clarity and consistency in the orders resulted in the facility's failure to meet the professional standards of quality care as required by the Pennsylvania Nursing Practice Act and the comprehensive care plan regulations.
Plan Of Correction
Resident 48 had no adverse reactions to having wound care orders not matching the wound physician's orders from rounding notes. Physician's order has been updated and the electronic medical record (EMR) reflects update. Resident 48 has since been discharged from the facility. A facility-wide sweep on all in-house residents with active wound care orders was conducted to ensure all rounding wound care physician orders were correctly transcribed into the EMR. Any issues identified were corrected at time of discovery. The wound care coordinator and all licensed nursing staff was re-educated on transcription of wound care orders from the rounding wound physician into the EMR. The Assistant Nursing Home Administrator or designee will conduct audits to ensure that EMR orders for wound care match the MD rounding report from the rounding wound physician, weekly X4 weeks then monthly X2 months. Identified issues will be addressed at time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.