Failure to Obtain Physician Order for Skin Tear Treatment
Penalty
Summary
A deficiency occurred when the facility failed to obtain a physician order for the treatment of a right lower arm skin tear for a resident with diagnoses including hemiplegia, aphasia, and chronic systolic congestive heart failure. The resident's care plan included an intervention to perform treatments as per physician orders, and the resident was assessed as having moderate cognitive impairment. Documentation showed the skin tear was first identified and measured, and wound care was provided, but there was no corresponding physician order for the treatment in the resident's medical record for the relevant period. Observations confirmed the resident had a dressing on the right arm, and interviews with staff, including a CNA and the DON, verified that wound care was being provided without an active physician order. The DON acknowledged that although a treatment plan was obtained, it was not written as a physician order. Facility policy required wound care to be provided using professional standards of practice, which was not followed in this instance.