Failure to Obtain Timely Treatment Order for Burn Abrasion
Penalty
Summary
The facility failed to obtain a treatment order for a burn abrasion for one resident upon admission. The resident was admitted with multiple diagnoses, including inflammatory polyarthropathy, muscle weakness, adult failure to thrive, and a burn of unspecified degree on the upper back. The admission skin assessment documented an open abrasion on the left scapula, and wound rounds identified an active abrasion with scant serosanguinous drainage. Despite these findings, there was no physician order for treatment of the burn abrasion from the time of admission until two days later. The plan of care indicated the need for skin treatments as ordered, and facility policy required that a physician be notified of skin alterations and that treatment be initiated as ordered. The Assistant Director of Nursing confirmed that the admitting nurse did not obtain a treatment order for the abrasion, particularly as the admission occurred over a weekend. This lapse resulted in the resident not receiving timely treatment for the skin alteration as required by facility policy and the resident's care plan.