Failure to Transcribe and Administer Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice and physician orders for a resident admitted with multiple diagnoses, including heart failure, diabetes, morbid obesity, and a recent vascular surgery to the left groin. Upon admission, the resident had a surgical wound with specific physician orders for wound care, including cleansing with normal saline, patting dry, and applying a dry dressing twice daily. However, the physician's order for wound care was not transcribed onto the Treatment Administration Record (TAR), making it impossible to verify that the ordered wound treatments were completed as prescribed. Nursing documentation showed inconsistent wound care entries, with gaps in documentation and changes in the wound's condition, including increased drainage and eventual signs of possible infection. Further review revealed that the wound worsened, with a contracted wound care nurse practitioner later documenting a deep, open, full-thickness wound with granulation and slough, and moderate seropurulent drainage. Diagnostic testing identified a fluid collection in the wound area, and the resident was subsequently sent to a vascular surgeon and admitted to the hospital for further treatment. The Director of Nursing confirmed that the failure to transcribe the physician's wound care order onto the TAR led to an inability to verify that the prescribed wound care was provided as ordered.