Conflicting Wound Care Orders and Incomplete Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with pressure ulcers, resulting in conflicting physician orders for wound treatment. During a wound care observation, a nurse prepared to apply Aquacel alginate to the wound bed, despite the current physician's order specifying the use of Xerofoam. The nurse stated she had confirmed with the physician that the Xerofoam order was correct and would remove the Aquacel order to prevent further confusion. However, both treatment orders remained active in the resident's record, and both were documented as completed on the Treatment Administration Record (TAR) on different dates. The resident involved had diagnoses including anemia, dysphagia, and high blood pressure, and was assessed as moderately impaired for daily decision-making, requiring dependent care for several activities of daily living. The care plan indicated the presence of pressure ulcers and directed staff to administer treatments as ordered. Despite this, the presence of two active, conflicting wound care orders led to inconsistent documentation and treatment practices, as evidenced by the TAR and direct observation.