Failure to Obtain Physician Orders for Wound Vac and Dressing
Penalty
Summary
A resident with a history of cellulitis of the right lower limb, type 2 diabetes mellitus, and an unstageable pressure ulcer to the right heel was observed to have a wound vac placed to the right heel following a recent hospital admission and surgical debridement due to infection. The wound vac was to be continued at 100 mmHg per the surgeon's request, with a rescue dressing of calcium alginate with silver, and specific instructions for dressing changes and wound care were documented in the Skin and Wound Note. Despite these clinical recommendations and the resident's complex wound care needs, there were no corresponding physician's orders for the wound vac or rescue dressing in the medical record for the month. The Director of Nursing confirmed that such orders should have been entered. Facility policy requires that wound treatments and physician's orders be documented in the medical record for residents with skin impairments, but this was not done for the resident in question.