Failure to Timely Transcribe Orders and Accurately Document Wound Care
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for multiple residents, as evidenced by untimely transcription of new treatment orders and inaccurate documentation of treatments. For one resident with a stage 2 pressure ulcer, staff did not consistently document wound care treatments on the Treatment Administration Record (TAR), with several missed entries and no explanation for delays in starting prescribed treatments. Additionally, after a surgical procedure resulting in a wound vacuum being placed, there was no physician order for the wound vac, and documentation of wound care remained incomplete. Another resident admitted with multiple pressure injuries, including a stage 4 ulcer and deep tissue injuries (DTIs), did not have all wounds identified or documented upon admission. The admitting nurse failed to document the presence of DTIs, and treatment orders for wounds were not initiated until several days after admission, with no documentation that the physician was notified of the delay. Hospital discharge instructions for wound care were not promptly transcribed or implemented, and the required skin assessment lacked complete wound descriptions. A third resident with a stage 4 pressure ulcer and additional wounds also experienced lapses in treatment documentation. Several wound care treatments and g-tube flushes were not documented as administered, and there was no record explaining the missed treatments or whether the physician was notified of delays in starting new orders. Interviews with facility staff confirmed that nurses were responsible for entering and documenting orders, and that documentation should occur at the time of service, but these practices were not consistently followed.