Failure to Schedule Wound Clinic Follow-Up per Physician Order
Penalty
Summary
The facility failed to follow a physician's order for a resident who was discharged from the hospital with multiple wounds, including an unstageable wound to the right buttocks and stage 3 wounds to the left buttock and sacrum. The discharge instructions specified that the resident should have a follow-up appointment at a wound healing clinic to resume grafix (skin graft) and wound vac therapy. However, interviews with the wound nurse, a registered nurse, and the Director of Nursing revealed that there was no documented evidence that this follow-up appointment was scheduled. The review of the resident's clinical record and order summary confirmed the presence of the physician's order for the wound clinic follow-up, but staff were unaware of the order and could not find any documentation that the appointment was made. The facility's policy indicated that written transfer orders from a hospital should be implemented without further validation, yet this order was not carried out. This lapse had the potential for the resident's wound to worsen.