Failure to Accurately Transcribe Wound Care Orders
Penalty
Summary
The facility failed to accurately transcribe wound treatment orders for a resident with a history of hemiplegia, hemiparesis following a stroke, and Type 2 Diabetes Mellitus, who was at risk for pressure ulcers due to immobility and incontinence. The resident's care plan included specific wound care instructions for a sacral pressure ulcer, with orders from the wound physician to apply a primary dressing of calcium alginate with silver, covered by a secondary island dressing. However, review of the Treatment Administration Records (TARs) over several months revealed discrepancies in the transcription of these orders. At times, the TARs listed the dressing as simply 'calcium alginate' without specifying the inclusion of silver, and the frequency of application was inconsistently documented. The treatment nurse acknowledged the oversight in transcription, stating that although the order was not transcribed correctly, the correct treatment was provided. Observations and interviews confirmed that the wound was being treated with the correct dressing, but the documentation did not consistently reflect the physician's orders. The wound physician noted that the omission of 'silver' in the order transcription was likely an oversight and that while the use of regular alginate would not have been detrimental, the silver component provided additional antimicrobial protection. Both the DON and the facility administrator stated that physician orders should be transcribed accurately. The resident's wound was nearly healed at the time of the survey, but the failure to correctly transcribe and document the wound care orders constituted a deficiency.