Failure to Clarify, Document, and Complete Physician-Ordered Wound Care
Penalty
Summary
The facility failed to ensure that physician orders for wound treatments were clarified, accurately documented, and completed as prescribed for two residents with non-pressure related wounds. For one resident with a history of hypertension, COPD, and peripheral vascular disease, a skin tear to the left shin was identified and treated initially, but no wound care treatment orders were entered into the medical record for several days, and there was no documentation that wound treatments were completed during that period. Observations confirmed that wound dressings were not applied as ordered, and staff verified that treatments had not been completed or documented as required. For another resident with cerebral infarction, spinal stenosis, and dementia, wound care orders were not updated or discontinued after wounds had healed. The treatment administration record indicated that wound care was documented as completed, but observations revealed that dressings were not applied according to orders, and some dressings were present without corresponding physician orders. Staff interviews confirmed that wound care orders were not discontinued when wounds healed and that wound care was not performed as documented. Policy review showed that the facility required verification of physician orders for wound care and accurate documentation of the care provided, including assessment data. The deficiency was identified through review of medical records, observations, and staff interviews, which revealed lapses in following physician orders, documentation, and communication regarding wound care treatments.