Failure to Obtain Treatment Orders for Non-Pressure Wound
Penalty
Summary
A resident with a history of ventilator dependence was admitted to the facility with a rash on the upper-mid vertebrae and an excoriation in the groin area. Physician orders were obtained for Miconazole Nitrate powder to treat the groin excoriation, but no treatment order was obtained for the rash on the vertebrae. Upon the resident's re-admission after a hospital transfer, the skin assessment again noted a rash on the vertebrae and an excoriation in the groin, with a continued lack of treatment orders for the vertebral rash. Staff interviews confirmed that although the rash on the back was observed, no treatment order was sought for this area during either the initial admission or re-admission. The resident was subsequently transferred to the hospital with complaints of a fungal rash on the back and a fungal infection in the groin and genital area. Hospital documentation indicated that the resident's labile blood pressure was likely due to the fungal infection. The Director of Nursing Services acknowledged that treatment orders were not initiated for the vertebral rash, and staff confirmed that only the groin rash was addressed per physician orders, despite the presence of additional skin impairments.