Failure to Accurately Transcribe and Implement Wound Care Orders
Penalty
Summary
A deficiency occurred when the facility failed to properly transcribe and implement a physician's wound treatment order for a resident with multiple diagnoses, including Parkinson's disease, mild cognitive impairment, and a history of skin impairment. The resident's care plan identified a risk for skin breakdown and included interventions to prevent pressure ulcers. On review, the wound care progress note recommended applying zinc to the peri-wound area of the right heel, along with collagen, Hydrofera Blue, and a dry protective dressing. However, the physician's order entered into the electronic health record omitted the zinc application, and treatment records did not show that zinc was applied as recommended. Interviews with the wound physician confirmed that zinc was intended to be part of the wound care regimen, and facility leadership acknowledged that the physician's order should have matched the treatment recommendation. The facility's policy required prompt and accurate entry of orders into the electronic health record, but this was not followed, resulting in the omission of zinc from the resident's wound care treatment.