Failure to Obtain Comprehensive Wound Care Orders Upon Admission
Penalty
Summary
The facility failed to obtain and document comprehensive wound treatment and dressing change orders upon admission for a resident with significant skin conditions, including a surgical wound and a venous stasis ulcer. The resident was admitted with chronic venous hypertension, cellulitis of the lower limbs, and a left foot abscess that had undergone surgical debridement. Hospital discharge records indicated the need for daily dressing changes and specific topical treatments, but did not provide clear or complete instructions for all affected areas. Upon admission, the nursing assessment and skin assessment identified multiple wounds, but the physician's orders only addressed topical application of Sodium Hypochlorite to foot ulcers, omitting detailed wound care and dressing instructions for the bilateral lower extremities and the surgical site. Nursing documentation showed that the resident required assistance with activities of daily living and had visible dressings on both lower extremities, with evidence of drainage on the left side. Despite this, the Treatment Administration Record and care plan interventions referenced wound care in general terms without specifying the type, frequency, or method of dressing changes for each wound. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing Services, confirmed that wound treatment orders were incomplete and that nursing staff had been applying dressings without proper physician orders since admission. Staff acknowledged that the hospital discharge instructions were unclear and that clarification should have been sought immediately upon admission. Further review revealed that the admitting nurse did not clarify or obtain the necessary wound care orders, and subsequent provider notes also failed to specify comprehensive wound care directives. The lack of clear, site-specific, and physician-authorized wound treatment orders resulted in nursing staff performing dressing changes without appropriate guidance. This deficiency was identified through observation, record review, and staff interviews, all of which confirmed that the required wound care orders were not in place at the time of admission.