Failure to Transcribe Wound Care Order to Treatment Record
Penalty
Summary
A resident with a diagnosis of chronic venous hypertension and bilateral lower extremity ulcers was admitted to the facility. The resident received a treatment order from the wound physician to cleanse a venous ulcer on the right lower lateral leg with normal saline, apply Xeroform, and cover with a dry dressing and Kerlix. However, review of the Treatment Administration Record (TAR) for the relevant month showed that this treatment order was not transcribed onto the TAR. During an interview, the treatment nurse confirmed that the wound care order was not present on the TAR, acknowledging that the wound might not receive the prescribed treatment if the order was not documented for licensed nurses to follow. The facility's policy requires that drug and biological orders be recorded on the physician's order sheet in the resident's chart, but this was not done for the resident's wound care order.