Failure to Obtain and Document Timely Wound Care Orders for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to obtain and implement physician orders for wound care for a resident who was admitted with a Stage IV pressure ulcer. The resident, who had a history of stroke with right-sided paralysis and severe cognitive impairment, was admitted from the hospital with a pressure area on the coccyx. Upon admission, there were no measurements or descriptions of the wound documented in the admission screener or nurse progress notes. Additionally, there were no wound care orders in place from the time of admission until several days later. Multiple nursing staff members acknowledged that the resident returned with a wound, but wound care treatments were not documented on the Treatment Administration Record (TAR) until several days after admission. Staff reported using various wound care products, such as Silvadene and calcium alginate, but could not consistently recall if or when physician orders were obtained or documented. Some staff believed they had communicated with a physician or nurse practitioner, but there was no clear record of timely orders or documentation in the resident's medical record. Facility policies required that verbal or telephone orders be documented by licensed personnel and that treatment orders specify the treatment, frequency, and duration. Policies also required a full assessment and documentation of pressure ulcers, including measurements and wound characteristics. These procedures were not followed, resulting in a lack of timely and appropriate wound care orders and documentation for the resident.