Failure to Transcribe and Implement Verbal Wound Care Order
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that a nurse practitioner's verbal wound care order was transcribed and implemented for a resident. The facility's policy requires that each wound site have a separate wound care order specifying the wound location, cleaning method, primary dressing, and frequency of dressing change. For a resident admitted with multiple diagnoses including Type 2 Diabetes Mellitus with a foot ulcer and muscle weakness, the care plan documented an actual impairment to skin integrity on the right rear thigh due to an abrasion. However, review of the physician's orders showed no wound care order for the abrasion, despite documentation in the skin and wound evaluation that described the wound and the treatment being provided. Observations confirmed that wound care was being performed on the abrasion, but the specific orders for cleaning, applying Nystatin powder and collagen, and covering with a dry dressing were not present in the physician's orders. Interviews with nursing staff and the wound care nurse practitioner confirmed that a verbal order for wound care had been given but was not transcribed into the resident's physician orders and therefore not formally implemented. This lapse resulted in the resident's wound care being conducted without the required physician order, contrary to facility policy and professional standards.