Failure to Administer Wound Care per Physician's Orders After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including CHF, COPD, atrial fibrillation, anxiety disorder, and personality disorder, sustained a laceration to the forehead following a fall. The resident's care plan required that the injury be treated according to physician's orders, which specified cleansing the wound with normal saline, applying bacitracin, and covering it with a band aid daily and as needed. Observations on two separate occasions revealed a band aid dated two days prior, with dark drainage noted underneath, indicating the dressing had not been changed as ordered. Review of the Treatment Administration Record (TAR) showed the treatment was signed off as completed, but there was no corresponding documentation in the nurse's notes for that day. Further investigation revealed that the LPN responsible for the treatment signed off the order as completed before actually administering it. The LPN admitted that she did not assess or change the dressing as ordered because the resident was sleeping when she attempted to provide care, and she acknowledged that she should not have signed off the treatment prior to its completion. The Director of Nursing confirmed that licensed nurses are not to sign off orders until they are administered. The facility was unable to provide a policy for physician's orders and treatment administration when requested.