Wound Care Provided Without Physician Orders
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to obtain physician orders for the treatment of a surgical wound and a pressure ulcer for a resident who was recently admitted with multiple complex wounds, including surgical incisions and pressure ulcers. During an observation of dressing changes, a registered nurse performed wound care on the resident's right arm surgical incision and left heel pressure ulcer without documented physician orders for these treatments. A review of the clinical record and Treatment Administration Record confirmed the absence of orders for these specific wound care treatments. The nurse acknowledged the lack of orders and was unable to locate any active orders for the required wound care.