Failure to Obtain Physician's Order for Catheter Dressing Care
Penalty
Summary
The facility failed to obtain a physician's order for the care and treatment of catheter dressings for a resident with a history of iron deficiency anemia, end stage renal disease, and recent hospitalization. Upon admission, the resident had a surgical wound from a right chest Permacath and a chemoport on the left upper clavicle, both covered with dressings. During interviews and record reviews, it was found that neither dressing was marked with initials or dates, and the resident reported that staff had not changed or removed either dressing since admission. Nursing staff, including a registered nurse and the North Unit Manager, confirmed there were no physician's orders regarding the management of the dressings on the resident's chest. The North Unit Manager recalled that the dressings were to remain in place until a specialty appointment but was unable to locate any physician's order to that effect. This lack of a physician's order meant that nursing staff did not have guidance on whether or how to provide care for the resident's chest dressings.