Failure to Enter and Implement Physician Wound Care Orders
Penalty
Summary
A resident with diagnoses including acute osteomyelitis, chronic myeloid leukemia, essential hypertension, and type 2 diabetes mellitus did not receive wound care treatment as ordered by their physician. The resident, who was cognitively intact, reported that new wound care treatments were ordered after a recent doctor's visit, but these treatments had not been initiated at the facility. Documentation showed that the physician's order for packing gauze and dressing change with betadine was not entered into the resident's medical record, and the most recent physician order sheet did not include these orders. Interviews with facility staff revealed a lack of communication and follow-up regarding changes in physician orders after appointments. The Regional Director of Clinical Services indicated that staff sometimes assume there are no new orders if residents do not provide paperwork, while the Administrator and Director of Nursing both stated that staff are expected to follow up with the physician's office and ensure all orders are entered into the medical record. Facility policies require prompt documentation and implementation of physician orders, but these were not followed in this case, resulting in a delay in the resident's wound care treatment.