Failure to Document and Implement Treatment Orders and Label Wound Dressings
Penalty
Summary
The facility failed to document and implement a prescribed treatment order for one resident diagnosed with scabies. Although a specialty physician ordered Permethrin (Elimite) 5% cream to be applied to the resident's whole body for 12 hours and repeated in seven days, there was no evidence in the electronic health record or treatment administration record that the order was documented or carried out. The Director of Nursing confirmed that the treatment order was not entered into the resident's records and that the resident was apparently not treated as prescribed. Additionally, the facility did not follow its own policy regarding the labeling and dating of wound dressings after treatment for two other residents. Observations showed that dressings on these residents were clean and intact but lacked required labeling and dating. The wound nurse acknowledged that staff were instructed to document wound care only in the treatment administration record and not to label or date the dressings, contrary to facility policy. These actions resulted in a failure to ensure proper documentation and implementation of wound care treatments as ordered.