Failure to Transcribe and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure that professional standards of practice for treatment orders were followed for two residents with non-pressure related skin wounds. In the first case, a resident with a surgical wound and wound VAC therapy was discharged from the hospital with detailed wound care orders, including specific instructions for dressing changes and the application of an alginate dressing to protect the periwound area. These orders were not transcribed into the facility's electronic health record (EHR), and the wound care provided did not follow the hospital's instructions. Observations confirmed that the required dressing components were missing, and the nurse responsible was unaware of the detailed orders. The nurse manager and DON both confirmed that the orders had not been transcribed and that the wound care provided was not in accordance with the physician's instructions. In the second case, another resident with a surgical incision following orthopedic surgery was seen by an orthopedic provider, who gave specific wound care orders, including allowing Steri-Strips to fall off naturally and permitting the incision to get wet in the shower. These orders were documented in the resident's paper chart but were not transcribed into the EHR. The nurse manager confirmed that only monitoring orders were present in the EHR and that the specific wound care instructions from the orthopedic provider were missing. The DON acknowledged that the facility was reviewing charts to ensure all post-appointment orders were transcribed. Facility policy required that treatment orders be transcribed accurately and in a timely manner and that ongoing treatments for skin issues follow provider orders. Despite these policies, the failure to transcribe and implement the detailed wound care orders for both residents resulted in care that did not meet professional standards. Interviews with nursing staff and management confirmed that the lack of transcription could disrupt the continuous plan of care and lead to inappropriate wound management.