Failure to Transcribe and Initiate Physician-Ordered Wound Care
Penalty
Summary
The facility failed to follow acceptable standards of clinical practice by not implementing a physician's order for wound treatment as prescribed for a resident with diabetes mellitus and a recent surgical amputation. The physician ordered wound care for the resident's right leg and right foot, specifically for the 3rd, 4th, and 5th toe amputation sites, to begin on a specified date. However, the treatment was not transcribed onto the Medication Administration Record (MAR) as ordered, resulting in a delay in the initiation of the prescribed wound care. This deficiency was identified when the clinical staff discovered during a clinical meeting that the wound treatments had not been entered into the MAR as required. The Director of Nursing confirmed that the physician's orders for the wound treatment were missed, and the facility's own policies require that all physician orders be entered into the electronic health record by the nurse or therapist accepting or transcribing the order. The failure to transcribe and initiate the wound care as ordered constituted a lapse in meeting professional standards of quality.