Failure to Accurately Transcribe and Implement Wound Care Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received necessary care and treatment to promote wound healing, specifically by not accurately transcribing and implementing wound care treatment orders according to the Wound Physician's recommendations. The facility's nursing staff did not consistently match wound locations and treatment orders with the physician's documentation, resulting in discrepancies between the actual wounds present and the active treatment orders. For example, the Right Anterior Ankle wound was not properly identified in the treatment orders, with orders instead written for the Right Dorsal Foot, and there were instances where two different treatment orders were active for what appeared to be the same wound. Additionally, treatment orders for wounds that had resolved, such as the Left Distal First Toe, remained active for an extended period after resolution. The resident involved had a history of severe protein malnutrition, type 2 diabetes mellitus, and previous skin cancer, and was admitted with multiple pressure ulcers requiring ongoing wound care. Throughout the review period, the medical record, treatment administration records, and wound physician summaries showed repeated failures to update, discontinue, or correctly transcribe treatment orders in accordance with the wound physician's recommendations. Orders for specific treatments, such as discontinuing Mupirocin 2% or changing to Calcium Alginate with Silver, were not implemented as recommended, and there was no documentation indicating that the attending physician declined these recommendations. The confusion was compounded by inconsistent anatomical descriptions and a lack of clear documentation regarding wound status and treatment changes. Interviews with the Wound Nurse and DON confirmed that there was confusion and error in the transcription and management of wound care orders. The Wound Nurse acknowledged that she was still learning the process and had not consistently cross-referenced the physician's written recommendations with the active orders. Both the Wound Nurse and DON noted that wound locations were used interchangeably, leading to multiple active orders for the same wound and continued treatments for wounds that had resolved. There was no evidence in the medical record or progress notes to support the continuation of certain treatments or to clarify discrepancies between the physician's recommendations and the orders implemented.