Failure to Document and Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to meet professional standards of care for wound management in three out of four residents reviewed. For one resident with a stage 4 sacral pressure ulcer and a non-pressure ulcer on the left third toe, there were discrepancies between the physician's treatment plan and the active orders in the medical record. The treatment administration record (TAR) did not include wound care for the left third toe, and documentation for coccyx wound care was missing on a specific date. The wound care nurse acknowledged that wound care was performed but not documented, attributing it to an oversight. Another resident with dementia and anxiety had an active physician order for coccyx wound care, but this order was not reflected in the TAR due to incorrect entry by nursing staff. The order was placed under the wrong section, resulting in the absence of documentation for wound care. The director of nursing confirmed that the order should have been discontinued as the resident no longer had a wound, but the lack of proper documentation and order management was evident. A third resident reported inconsistent wound care, stating that treatments were not performed as ordered. Review of the TAR showed missing documentation for wound care on multiple days, and the treatment frequencies entered did not match the physician's orders. The wound care nurse and DON acknowledged errors in order entry and documentation, with wound care not being documented or performed according to the prescribed schedule. Facility policies required accurate and timely documentation of wound care, which was not consistently followed in these cases.