Failure to Transcribe and Implement Wound Care Orders
Penalty
Summary
Facility staff failed to meet professional standards of quality by not transcribing and implementing wound care orders for two residents with pressure ulcers. For one resident, staff did not update the physician order sheet (POS) with new wound care instructions received from the wound clinic, resulting in the continued use of outdated treatment protocols. The wound nurse confirmed that the orders were not updated in the system because the nurse who received the new orders did not enter them, and the responsibility for updating orders was not clearly followed. Documentation on the Treatment Administration Record (TAR) showed treatments were administered according to the old orders, not the updated ones from the wound clinic. For another resident, the plan of care did not address the resident's wounds, and staff failed to document new wound care orders, including specific cleansing and dressing instructions. During observation, an LPN did not use the correct cleansing agents or dressings as prescribed in the new orders, instead using wound cleanser and foam dressings not specified in the orders. The LPN admitted to not updating the orders in the system and not following the prescribed wound care protocol, citing oversight as the reason for the errors. Interviews with staff, including the wound nurse, LPN, DON, and administrator, revealed a lack of clarity and consistency in the process for updating and implementing new physician orders. Staff acknowledged that it is the responsibility of the nurse receiving the orders to enter them promptly, but this was not consistently done. The DON and administrator were not aware that orders were not being updated or that wound care was not being performed as prescribed, indicating a breakdown in communication and adherence to facility policy.