Failure to Clarify and Implement Wound Care Orders
Penalty
Summary
A deficiency was identified when the facility failed to clarify and implement a provider's order for wound care treatment for one of eight residents reviewed. The resident, who was cognitively intact and required staff assistance for daily care, was admitted with a deep tissue injury and a pelvic fracture. Physician's orders initially directed specific wound care, and a subsequent wound consultant note recommended a change in treatment, including the use of acetic acid moist gauze. However, there was no documented evidence that the recommended treatment from the wound consultant was carried out between April 15 and April 20. Further review and staff interviews revealed that the physician was not informed of the wound consultant's recommendations until several days after they were made. This lapse resulted in a delay in updating the resident's treatment plan according to professional standards and the recommendations provided by the wound care consultant. The findings were based on clinical record review, staff interviews, and reference to the Pennsylvania Nursing Practice Act and relevant state codes.