Delayed Wound Care and Missed Physician Orders for Monitoring
Penalty
Summary
A deficiency was identified regarding the timely provision of wound care for a resident with a history of arterial disease, muscle wasting, and a recent toe amputation. Upon readmission, the resident was noted to have an open wound on the left third toe, but there was no active physician's treatment order or documented treatment for eight days following the initial identification of the wound. The wound nurse acknowledged that the wound was present and required treatment, but failed to transcribe the necessary order, resulting in a delay in care. Facility policy required prompt notification of the physician and documentation of treatment, which was not followed in this instance. Another deficiency was found in the administration and documentation of physician-ordered monitoring for a resident receiving a new dose of antipsychotic medication. The resident, who had multiple psychiatric diagnoses and moderate cognitive impairment, was prescribed Zyprexa and required weekly orthostatic blood pressure checks for four weeks following a dose change. Although the Treatment Administration Record indicated that these checks were completed, there was no supporting documentation in the clinical record to confirm that the blood pressures were actually taken as ordered. Nursing staff could not account for the missing documentation, despite being aware of the requirements for orthostatic blood pressure monitoring. Both deficiencies were confirmed through review of clinical records, facility policies, and staff interviews. The failures involved not implementing physician orders as prescribed and not providing timely, documented care in accordance with established protocols and resident care plans.