Failure to Timely Implement and Document Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to follow physician's orders for wound care treatments for a resident with a history of severe cognitive impairment, cerebral palsy, orthostatic hypotension, depression, and pressure ulcers. Multiple wound nurse practitioner (NP) assessment reports documented changes in wound care orders for a Stage 4 pressure ulcer to the left ischium, including specific instructions for cleansing, application of collagen or Dakins solution, and dressing frequency. However, there were repeated delays in initiating new treatment orders, with some orders not implemented until several days after being written. Additionally, some orders were transcribed incorrectly, such as a daily treatment being entered as twice daily, and negative pressure wound therapy orders not being updated in a timely manner. Review of the electronic treatment administration record (ETAR) revealed several dates where documentation of wound care was missing, indicating that treatments were not completed as ordered. Interviews with the Assistant Director of Nursing (ADON) confirmed that orders were either transcribed incorrectly or not implemented in a timely fashion, and that missing documentation in the ETAR meant the treatment was not performed. The facility's policy required following physician orders, but this was not consistently done for the resident's pressure ulcer care.