Failure to Complete and Document Physician Wound Care Orders and Ensure Clinic Access
Penalty
Summary
The facility failed to follow professional standards of practice by not completing physician orders for wound care as prescribed for two residents. For one resident with a Stage III pressure ulcer on the left heel, multiple orders from the contracted wound care company, including the application of ace wraps from toes to knee and specific dressing changes, were not transcribed onto the physician order sheet (POS) or the Treatment Administration Record (TAR). As a result, these treatments were not documented as completed, and previous orders were not discontinued when new orders were received, leading to overlapping and potentially conflicting wound care treatments. Another resident with multiple pressure ulcers, including a Stage III sacral ulcer, did not have updated wound care clinic orders entered into the POS or documented on the TAR. Orders for wound cleansing, dressing applications, and wound vac management were either missing or incomplete in the records. On several occasions, staff failed to document that wound care treatments were performed as ordered, and there were discrepancies between the wound care clinic's recommendations and what was recorded in the facility's records. Additionally, the facility failed to ensure that this resident had transportation to scheduled wound care clinic appointments, resulting in missed visits. Interviews with nursing staff revealed that orders from the wound care clinic were sometimes missed or not fully transcribed into the POS, and there was no clear process to ensure that all faxed orders were reviewed and entered correctly. The Director of Nursing confirmed that documentation was expected to match the wound care company's orders and that staff were expected to follow treatment orders as directed.