Failure to Implement and Communicate Wound Care Orders for Diabetic Ulcers
Penalty
Summary
The facility failed to obtain and implement treatment orders for a resident with diabetic ulcers, resulting in a lack of timely wound care. The resident, who had a history of diabetes and osteomyelitis, was admitted with multiple arterial and diabetic foot ulcers. Documentation showed that after returning from the wound clinic, new treatment orders were not consistently implemented or reflected in the Treatment Administration Record (TAR). The resident reported a preference for wound care at the clinic and noted that clinic orders were not always followed by the facility. Staff interviews revealed inconsistent processes for verifying and implementing new wound care orders after the resident's visits to the wound clinic. Communication challenges between the facility and the wound clinic were reported, with staff indicating that orders were sometimes requested but not received, and agency staff were not always aware of the procedures. The nurse practitioner did not coordinate communication between the resident's multiple providers, and the regional clinical director expected timely verification and implementation of wound care orders, which did not occur.