Failure to Obtain and Implement Physician Order for Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to obtain and implement a physician's order for the treatment of a skin tear sustained by a resident with severe cognitive impairment, including Parkinson's disease and dementia. The resident was observed with a visibly soiled, undated foam dressing on the right forearm, and was unable to communicate details about the injury or the dressing. Review of the medical record from the relevant period showed no documentation of the skin tear, no physician's order for wound treatment, and no evidence that appropriate wound care was implemented. Interviews with staff revealed that the dressing was applied by a nurse several days prior without a physician's order, and the dressing may not have been changed since its initial application. The unit manager confirmed that the order for wound treatment was not obtained until at least three days after the injury, only after the issue was identified by the surveyor. Facility policy and state nursing guidelines require physician orders for wound treatments, which were not followed in this instance.