Failure to Provide Burn Treatment as Ordered
Penalty
Summary
A deficiency was identified when a resident with significant burn injuries to both thighs did not receive treatment as ordered by her physician. The resident's care plan included interventions for impaired skin integrity, specifically requiring the application of Aquaphor ointment to both thighs twice daily to prevent dryness and promote healing. Physician instructions also included daily gentle washing of the lower extremities and moisturizing the wounds twice a day. However, review of the Treatment Administration Record (TAR) and interviews revealed inconsistencies and lapses in the administration of the prescribed treatment. During observation and interviews, the resident reported that staff had not been applying the Aquaphor treatment as ordered for two weeks, resulting in dry, itchy, and peeling skin on her thighs. The resident showed the surveyor her burns, which appeared dry and lacked the expected moisturized appearance. Staff interviews revealed confusion regarding the application process, with one RN admitting to being distracted and not completing the treatment, and the ADON stating she applied the ointment only after being asked by another nurse. The resident also noted that the area was not washed prior to application, contrary to the specialist's instructions. Further interviews with facility staff, including the Regional Compliance Nurse and the Administrator, confirmed that there were gaps in the transcription and monitoring of physician orders, leading to the resident not receiving care as prescribed. The facility's policy on documentation of new or changed physician orders did not address the need to follow physician orders, contributing to the failure to provide appropriate treatment and care according to the resident's needs and medical directives.