Failure to Follow Physician's Wound Care Orders for Surgical Incision
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician's orders for a resident who was admitted with multiple complex medical conditions, including recent cardiac surgery. The resident's hospital discharge instructions specifically ordered daily cleansing of a surgical incision with soap and water, monitoring for signs of infection, and avoiding lotions or ointments on the site. However, upon review of the resident's electronic Treatment Administration Record (eTAR) and medical record, there was no evidence that an order to wash the incision daily was entered or carried out during the resident's stay. The only documented intervention was monitoring the incision site, with no record of actual cleansing as directed by the physician's order. Interviews with facility staff revealed that the wound care nurse overlooked the order to wash the incision daily and did not ensure the order was entered or followed. The Director of Nursing was unaware of the wound care order and stated that such orders are typically managed by the wound care nurse, who coordinates with the facility's wound care physician or nurse practitioner. The facility's policy requires that treatment orders specify the treatment, frequency, and duration, and that a current list of orders be maintained in each resident's clinical record. This process was not followed, resulting in the omission of the required wound care for the resident.