Failure to Obtain and Document Physician Orders for Wound Care
Penalty
Summary
The facility failed to obtain and document physician orders for wound care for two residents with significant wounds. For one resident with a chronic right lateral thigh abscess, the clinical record showed that after returning from the emergency room with instructions for wound packing and antibiotics, there was no evidence of wound care orders or documentation of wound care provided from the date of return until nearly two weeks later. Nursing staff acknowledged having the ER discharge summary but were unable to locate it in the medical record, and could not provide documentation of wound care orders or provider instructions during this period, except for a single wound assessment. For another resident requiring negative pressure wound therapy (NPWT), a malfunction in the wound vac led to the wound being packed with VASHE-soaked gauze. Although nursing staff reported obtaining a verbal order from the provider for this alternative dressing, there was no documentation of such an order in the resident's medical record. These lapses resulted in the absence of required provider orders for wound care interventions as specified in the residents' care plans and clinical needs.