Failure to Transcribe Physician Orders and Notify Administration of New Skin Injury
Penalty
Summary
A deficiency occurred when nursing staff failed to follow professional standards of practice in the care of a resident who sustained a thermal burn to the left upper thigh. The resident, who had diagnoses including urogenital implants and neuromuscular dysfunction of the bladder, required staff assistance with most activities of daily living and had intact cognition. The burn was identified as a second-degree, in-house acquired injury, and was first noted by the resident, who reported it to nursing staff after returning from an eye appointment where they had spilled hot coffee on themselves. Upon assessment, the wound was described and measured, and a treatment plan involving a wound cleanser and silver sulfadiazine was indicated. However, there was no evidence that a physician's order for the silver sulfadiazine was transcribed into the electronic medical record, nor was there documentation of the treatment being applied on the treatment administration record for the date the wound was identified. Additionally, the nurse who first identified the burn did not notify the Director of Nursing or the Administrator about the new injury, nor did they document the application of an abdominal pad or the completion of the identified treatment in the resident's record. The lack of timely transcription and implementation of physician orders, failure to document wound care, and failure to notify administration of a new skin injury resulted in the facility not meeting professional standards of quality for nursing services. These actions and omissions were confirmed through observation, record review, and interviews with facility staff.