Failure to Transcribe and Implement Wound Care Orders Resulting in Infection
Penalty
Summary
A deficiency occurred when a resident was admitted with a dehisced surgical wound to the lower back and specific wound care orders from the hospital, including cleansing with vashe, application of aquacel AG advanced, and covering with a mepilex dressing. These orders were not transcribed or implemented by facility staff for six days following admission. During this period, nursing staff documented that the surgical site was clean and dry, but did not follow the prescribed wound care regimen. The resident, who had diagnoses including a stable burst fracture of the fifth lumbar vertebra and uterine cancer, was dependent on staff for personal care and was incontinent of bowel and bladder. The wound was not assessed or treated according to the hospital's discharge instructions, and the facility's wound nurse was not made aware of the wound until several days after admission. The omission was discovered when a nurse detected a foul odor and found the dressing saturated with purulent drainage, indicating infection. At that point, the nurse located the original hospital orders and implemented the appropriate wound care, and the resident was started on antibiotics after the infection was identified. The delay in transcribing and implementing the wound care orders resulted in the resident developing an infected surgical wound with purulent drainage and significant slough covering most of the wound bed. The resident subsequently became lethargic and was transferred to the hospital for further evaluation. The failure to follow the physician's orders for wound care directly led to the infection and deterioration of the resident's condition.