Failure to Follow Physician Orders and Properly Transcribe Readmission Orders
Penalty
Summary
For one resident, a failure to follow the physician's order for wound care was observed. The resident, who had intact cognition and required assistance with personal care, had a physician's order to have a right wrist skin tear cleansed and dressed daily and as needed. Despite the dressing being visibly soiled and wet after a shower, the nurse on duty did not change it, stating that the dressing was scheduled to be changed later in the day. The resident expressed an expectation that the dressing would be changed immediately due to its condition, but the nurse walked away without addressing the issue. The Director of Nursing confirmed that the dressing should have been changed when it was found to be soiled or wet, not just according to the scheduled time. For another resident, the facility failed to ensure that re-admission orders from the emergency room were properly reviewed and transcribed. Upon return from the ER with a diagnosis of cellulitis at the PEG tube site, the resident was to receive Bacitracin ointment twice daily for ten days. The LPN entered the order into the electronic medical record without reviewing the ER discharge order with the facility's on-call provider, as required by facility protocol. Additionally, the night shift nursing staff was unaware of the new order, and the RN/House Supervisor confirmed that the standard process of reviewing discharge orders with the provider was not followed.