Incomplete Documentation of Verbal Wound Care Orders and Treatment
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who had undergone a panniculectomy and experienced wound dehiscence and infection. Although there was a physician order for wound vac dressing changes three times per week, on one occasion the wound vac stopped working and an alternate dressing was applied. The nurse documented the wound treatment as held and referenced nursing progress notes, but there was no corresponding physician order for the alternative dressing in the record for the period when the wound vac was unavailable. Interviews revealed that the nurse had received a verbal order from an APRN to apply a wet to dry dressing until the new wound vac arrived, but this verbal order was not documented in the electronic medical record as required by facility policy. Both the nurse and the APRN confirmed that verbal orders should be entered into the EMR, and the facility's policies direct that such orders be written down, verified, and properly documented. Additionally, documentation of the wound care provided was not completed in a timely manner, as required by the facility's nursing documentation policy.