Failure to Follow Physician's Wound Care Orders and Document Treatment
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order for wound care and did not document the treatment provided to a resident with hemiplegia, hemiparesis, obstructive and reflux uropathy, and chronic kidney disease. The physician's order specified that urea cream 40% should be applied to both lower extremities after a shower or bed bath, and the legs should be wrapped with kerlix every dayshift for 30 days. Observations and interviews revealed that the treatment nurse did not consistently apply the lotion or wrap the resident's legs as ordered. On multiple occasions, the resident's lower legs were not wrapped, and the resident reported that the treatment was not performed daily as prescribed. Review of the Treatment Administration Record (TAR) for several consecutive days showed no documentation of the wound care treatment. The LVN responsible for the care confirmed that she did not document the treatments on those days and acknowledged that if the treatment was not documented, it was not done. The Director of Nursing also confirmed the importance of following physician orders and documenting wound care in the TAR, as required by facility policy. The facility's policy stated that the name and title of the individual performing wound care should be documented in the clinical record.