Failure to Transcribe and Implement Physician Orders for Wound Care
Penalty
Summary
The facility failed to properly transcribe and implement physician orders for a resident who was admitted with a diagnosis that included a displaced comminuted fracture of the left humerus. Upon review of the resident's clinical record, it was found that instructions for wound care, specifically an icing protocol outlined in the After Visit Summary, were not transcribed into the resident's medical record. As a result, there was no order for the application of ice to the resident's wound until several days after admission. Interviews with facility staff revealed that the process for transcribing new admission orders involved Unit Managers entering the orders into the computer, with a second nurse expected to verify them. However, this process was not followed, and the omission was only discovered after a family member alerted staff that the resident was not receiving the prescribed ice therapy. The lack of transcription led to a delay in the implementation of the physician's wound care instructions.