Failure to Transcribe and Implement Physician's Wound Care Order
Penalty
Summary
The facility failed to provide care for a surgical wound as ordered by a consultant orthopedic physician for one resident. The resident, who had a closed fracture of the right femur with routine healing, was admitted without specific surgical wound care instructions from the hospital. However, a subsequent orthopedic consultation resulted in an order for a daily dry dressing change to the right hip. This order was not transcribed into the facility's electronic health record, and there was no documentation of the daily dressing change on the Treatment Administration Record. Multiple nursing staff members were unaware of the order and did not perform or communicate the required dressing changes. Interviews revealed that the DON, who was acting as unit manager at the time, was responsible for reviewing the orthopedic note and entering the order but failed to do so due to an oversight. Nursing staff assigned to the resident during the relevant period did not recall receiving or acting on the consultation paperwork and were unaware of the daily dressing change order. As a result, the resident did not receive the prescribed wound care prior to discharge, and neither the resident nor their representative was informed about the daily dressing change requirement.