Failure to Provide Physician-Ordered Wound Care After Dermatology Procedure
Penalty
Summary
A deficiency occurred when the facility failed to provide physician-ordered wound care following a dermatology procedure for a resident with a history of cerebral infarction and atrial fibrillation. The resident, who was cognitively intact, underwent a micrographic surgery to remove skin cancer and returned to the facility with specific wound care instructions, including washing the biopsy area, applying Vaseline or mupirocin, covering with Telfa and paper tape, and monitoring for signs of infection. These orders were not transcribed onto the Medication Administration Record (MAR) or Treatment Administration Record (TAR), resulting in the wound care not being performed as prescribed. The issue was identified when the resident reported to surveyors that, during a follow-up visit, the dermatologist noted an infection in the wound due to lack of wound care. The Director of Nursing confirmed that while the orders were entered into the electronic health record, they were not directed to the MAR or TAR, leading to the omission of the required treatment. Subsequent documentation showed that the resident required additional medical intervention, including a new wound care order and an oral antibiotic, after the infection was identified.