Failure to Transcribe Physician Orders and Complete Weekly Skin Assessments
Penalty
Summary
Facility staff failed to meet professional standards of practice by not transcribing physician's orders for one resident and not completing weekly skin assessments for three residents. For one resident with severe cognitive impairment and at risk for skin breakdown, a wound consultant ordered a hydrocolloid sheet to be applied weekly and as needed, but this order was not transcribed into the resident's Physician Order Sheet (POS) or Treatment Administration Record (TAR). The wound care nurse and charge nurse both acknowledged that the process for entering new wound care orders was not followed, and the wound care nurse did not verify that the orders were entered as required. Additionally, weekly skin assessments were not documented as completed for three residents who were all assessed as being at risk for skin breakdown and requiring assistance with activities of daily living. Review of the residents' records showed multiple missed weekly skin assessments over several months, despite standing physician orders for these assessments to be completed by licensed staff on specific days. Interviews with staff, including the DON, wound care nurse, and administrator, confirmed that the responsibility for entering new orders and completing weekly skin assessments was not consistently fulfilled. Staff interviews revealed a lack of clarity and follow-through regarding the process for transcribing and verifying physician orders, particularly those from the wound consultant. The facility's policy required all physician orders to be carried out as ordered and entered into the electronic medical record, but this was not done. The DON, wound care nurse, and administrator all stated that if something is not documented, it is considered not done, and acknowledged that the required documentation and follow-up were missing in these cases.