Failure to Implement Dietician Recommendations for Wound Care
Penalty
Summary
Nursing staff failed to ensure that professional standards of quality were met for a resident who required nutritional interventions for wound care. The resident, admitted with a new surgical wound following a below-the-knee amputation and with multiple diagnoses including peripheral vascular disease and diabetes, was assessed by the Registered Dietician (RD) who recommended starting a multivitamin (MVI), adding 30 ml of liquid protein, and including yogurt at breakfast. While the addition of yogurt was ordered, there was no documentation that the recommendations for the MVI and liquid protein were communicated to the physician or implemented. The RD made these recommendations on two separate occasions, but neither the Director of Nursing (DON) nor the Nurse Clinical Manager were aware that the recommendations had not been addressed. The facility's process required the RD to upload recommendations to a portal and email a report to the DON, who would then distribute the recommendations to the appropriate staff for physician review and order implementation. However, this process was not followed, resulting in the resident not receiving the recommended nutritional interventions in a timely manner.