Failure to Timely Transcribe and Implement Pressure Ulcer Dressing Order
Penalty
Summary
Staff failed to provide care consistent with professional standards of practice by not timely and accurately transcribing a new physician order for a pressure ulcer dressing change for a resident. The resident, who had multiple significant diagnoses including sepsis, type one diabetes mellitus, encephalopathy, and chronic respiratory failure, was identified as having a pressure ulcer. During a wound assessment and care plan review, a new order was written by the wound physician specifying the use of collagen powder and calcium alginate for the left ischial tuberosity wound, to be applied daily and as needed. However, the order was not correctly transcribed by the LPN on the day it was written, specifically omitting the application of calcium alginate to the wound. This error was not identified or corrected until seven days later. The facility's policy requires licensed nurses to accurately transcribe and initiate physician orders, but this process was not followed in this instance. The resident's wound area did not increase during this period, but the care provided was not in accordance with the physician's instructions.