Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that physician orders for wound care were consistently followed for one resident with multiple wounds. Review of the clinical record, care plans, and the Electronic Medication Administration Record (EMAR) revealed that several wound treatments were not documented as completed on multiple dates, despite active physician orders. The facility's policy requires all physician orders to be implemented and followed as received, but documentation gaps were identified for various wound care treatments, including the application of Betadine, Medihoney, and the use of pillow boots and gauze for wounds on the resident's toes and foot. The resident involved had a complex medical history, including cerebral infarction, hemiplegia, diabetes, dysphagia, aphasia, peripheral vascular disease, and recent toe amputations. The care plans detailed multiple wounds and interventions, such as skin assessments, wound treatments, and the use of pressure-reducing devices. The resident also exhibited behavioral symptoms, including restlessness and resistance to care, which sometimes resulted in the removal of dressings and boots. Despite these challenges, the EMAR showed that wound care treatments were not signed as completed on several occasions, indicating a lack of adherence to physician orders. Specific dates were identified where wound care orders were not documented as completed, including treatments for abscesses, arterial ulcers, and post-amputation care. The deficiency was confirmed through observation, interview, and record review, and the facility's policy on following physician orders was provided by the Director of Nursing. This failure to document and ensure completion of ordered wound care services constituted a deficiency under the cited regulation.