Wound Care Provided Without Physician Order
Penalty
Summary
A Licensed Vocational Nurse (LVN) provided wound care to a resident without a physician's order. The resident, who had been admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and sepsis, was observed with a skin tear on her left hand. The LVN removed the resident's bandage, cleansed the wound, applied A&D ointment, placed a calcium alginate dressing, and covered it with an island dressing. Review of the Treatment Administration Record (TAR) confirmed there was no active wound care order for this resident at the time of the treatment. During interviews, the LVN acknowledged that a physician should have been contacted to obtain a new wound care order before providing treatment. The Director of Nursing (DON) confirmed that staff are expected to update the physician and obtain appropriate orders for wound care. The facility's wound care policy also requires verification of a physician's order prior to performing wound care procedures. The pharmacist noted that improper use of calcium alginate could delay wound healing.