Failure to Transcribe and Implement Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to accurately transcribe and implement physician orders for pressure ulcer treatment for a resident admitted with an active diagnosis of a sacral pressure ulcer, altered mental status, and osteoarthritis. The hospital discharge summary specified that Medihoney should be applied and covered with Mepilex daily to the sacral pressure ulcer. However, upon admission, the facility did not enter this pressure ulcer care order into the resident's order set. Documentation from the Director of Nursing (DON) indicated that the pressure ulcer was treated with Medihoney and Mepilex on admission, but no formal treatment order was found in the resident's records. Further review showed that on a later date, a Registered Nurse (RN) noted changes in the wound's condition and reported a change in treatment to Hydrogel and Mepilex after consulting with a Nurse Practitioner. Despite this, there was no documentation of a change order or any pressure ulcer treatment orders until several days after admission. Interviews with the DON and RN revealed that care was provided based on verbal reports rather than documented orders, and neither could locate the necessary treatment orders or explain the lack of documentation.