Failure to Follow Physician Orders and Perform Wound Care
Penalty
Summary
The facility failed to follow physician orders and provide daily wound care for one resident with a recent left below knee amputation (BKA) and diabetes. The resident was admitted for wound care and other skilled services, with physician orders specifying daily dressing changes to the amputation site. Despite these orders, the resident reported that wound care was not performed over the weekend following admission, and the first dressing change occurred only on the following Monday. The Treatment Administration Record (TAR) inaccurately indicated that wound care was completed on Saturday, but the nurse responsible confirmed that the dressing change was not performed as documented. Further review revealed that the wound care coordinator placed the necessary orders after being contacted by staff, but the assigned wound care nurse did not carry out the dressing change as required. Additionally, there was no documentation of wound care being performed on Sunday, and the wound care coordinator was unsure why the scheduled nurse did not complete the task. Facility policies require adherence to physician orders and timely wound care, but these were not followed in this instance, resulting in a lapse in care and inaccurate recordkeeping.