Failure to Notify Physician and Implement Wound Care Orders
Penalty
Summary
A deficiency occurred when a licensed nurse failed to notify the physician after a resident experienced a significant change in mental status. The resident, who was admitted following an orthopedic surgical amputation, was initially alert and oriented to person, place, and time. However, nursing progress notes documented a decline to being alert and oriented to person only. Instead of directly notifying the physician as required by facility policy and the hospital discharge instructions, the nurse left a message in the facility's communication binder regarding the change in condition. Additionally, the facility failed to transcribe and implement a wound care order from the resident's hospital discharge instructions. The discharge orders specified daily dressing changes for the surgical site, but this order was not entered into the SNF physician orders or the Treatment Administration Record. As a result, the wound dressing was not changed for two days. Both the wound care nurse and the DON confirmed that the wound care order was missing from the resident's SNF orders, and the wound care nurse was unaware of the need for dressing changes during that period.