Failure to Implement Physician Orders for Fracture and Wound Care
Penalty
Summary
The facility failed to implement physician orders and provide appropriate care for two residents with specific medical needs. For one resident with end stage renal disease, diabetes mellitus type two, and chronic obstructive pulmonary disease, there was no documentation of orders or care plans for a left ankle fracture and splint following a hospital stay, despite the resident returning with a splint in place. Staff interviews confirmed the absence of orders and care plans related to the splint and fracture care during the resident's stay. Another resident with end-stage renal disease, cerebral infarction, and type two diabetes mellitus returned from the hospital with instructions for wound care to a right lower leg ulcer, specifically a wet-to-dry dressing change every eight hours. The facility did not implement these orders, and there was no documentation of physician contact for clarification. Updated wound care orders from a wound clinic were also not implemented until two days after they were received. Staff interviews confirmed the delay and lack of implementation of both the hospital and wound clinic orders for wound care.