Failure to Obtain Physician Orders and Maintain Communication for Wound and Hospice Care
Penalty
Summary
The facility failed to ensure proper physician orders and routine assessments for wound care and medication administration for a resident with an abrasion. Specifically, a licensed nurse was observed applying mupirocin ointment to a resident's head without a corresponding physician's order, and the medication was kept at the bedside. There were no documented assessments or physician's orders for the abrasion, despite facility policy requiring weekly skin evaluations and care consistent with professional standards. The resident, who had an intact cognitive status, reported that staff applied ointment to the abrasion, and the beauty operator confirmed placing cotton on the wound after it bled during hair washing. The Director of Nursing and LPN were unable to locate any active orders or assessments related to the abrasion or the use of mupirocin. Additionally, the facility did not maintain adequate communication with hospice services regarding another resident's oxygen therapy. An oxygen concentrator and tanks were observed in the resident's room, and hospice documentation indicated an order for oxygen therapy. However, this order was not reflected in the resident's physician orders within the facility. Both the LPN and DON acknowledged the absence of a physician order for oxygen in the facility records, attributing the issue to a communication lapse with hospice. The resident, who was cognitively intact, was unsure how to contact hospice to discuss their care.