Wound Care Provided Without Physician Order or Documentation
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including atrial fibrillation, morbid obesity, and hemiplegia, was found with a wound patch on the right arm that lacked a corresponding physician's order and proper documentation. During observation, the wound patch was noted to be dated several days prior, and review of the electronic health record confirmed there was no physician's order or nursing note regarding the application of the patch. The resident's care plan had been updated to reflect risks and history of impaired skin integrity, but the specific wound care provided was not documented as required. Interviews with facility staff, including an LPN and the DON, confirmed that the wound patch was applied without a physician's order and that the physician had not been notified about the wound or the treatment provided. The DON acknowledged that all treatments should be documented and that the physician should have directed the wound care. Review of facility policy further indicated that physician authorization is required for wound treatments, but this protocol was not followed in this instance. No additional documentation or information was provided by the facility at the time of the survey.