Failure to Transcribe and Implement Physician Orders for Compression Stockings and Wound Care
Penalty
Summary
The facility failed to properly transcribe and implement physician orders for a resident who required monitoring and care for edema and a surgical incision. The resident had multiple complex diagnoses, including infection and inflammatory reaction due to a joint prosthesis, heart failure, cellulitis, and respiratory failure. Physician orders included the use of compression stockings (ted hose) and specific wound care instructions, but these were not consistently transcribed into the treatment administration record (TAR) or medication administration record (MAR), resulting in a lack of documentation and implementation by nursing staff. Observations and interviews revealed that the resident was not wearing the prescribed ted stockings and was managing wound care independently, as staff were unaware of the current orders. The resident reported that staff never assisted with the ted stockings or wound care, and he had to perform these tasks himself. Documentation for wound care orders was either missing or not completed, and the order for ted stockings was not visible to nurses in their daily assignments due to improper transcription in the electronic health record system. Interviews with facility staff, including the ADON, LPN, and DON, confirmed that the orders for ted stockings and wound care were not properly processed or carried over into the nurses' daily assignments, making them inaccessible for routine care. The resident's care plan was not updated to reflect the need for ted stockings or address edema, and there were no reviews or updates to the wound management care plan after the initial entry. This resulted in the resident not receiving care as ordered and required by his condition.