Failure to Timely Implement and Accurately Transcribe Wound Care Orders
Penalty
Summary
Nursing staff failed to provide care and services that met professional standards of practice for a resident who was re-admitted with multiple pressure injuries. Upon re-admission, the resident had a history of diabetes mellitus with neuropathy, peripheral vascular disease, and hemiparesis, and had recently returned from a 10-day hospital stay. The wound physician made several recommendations for wound care, including specific treatments for four separate pressure injuries, but these recommendations were not promptly or accurately transcribed into physician orders or implemented by nursing staff. Review of the resident's medical record revealed that nursing continued to follow outdated and incomplete treatment orders for the resident's wounds, despite new recommendations from the wound physician. There was a significant delay in obtaining and documenting new orders for the recommended treatments, with some not transcribed until over a month after the recommendations were made. Additionally, there was a lack of documentation to support that certain wound care interventions, such as the use of a pressure off-loading boot and heel elevation, were ever implemented as recommended. Interviews with nursing staff and management indicated confusion and lack of clarity regarding responsibility for obtaining and transcribing new wound care orders. Staff members reported that the unit manager was responsible for reviewing consultant recommendations and obtaining new orders, but there was no evidence that this process was completed in a timely or accurate manner. The interim DON was unaware that the wound physician's recommendations had not been followed or that orders were not accurately transcribed.