Delay and Incomplete Implementation of Burn Treatment Orders
Penalty
Summary
The facility failed to promptly implement a physician's recommendation for burn treatment and did not ensure the treatment was ordered at the recommended frequency. A resident with a history of extensive burns and skin grafts, who was cognitively intact, was admitted with orders from a Burn/Wound center physician to apply cocoa butter to all healed areas three times daily. However, the physician order entered into the Electronic Medical Record (EMR) two days after the consultation specified application only once per day shift and only to certain areas, not matching the recommended frequency or coverage. Further review showed that the cocoa butter was not available until several days after the order was approved, resulting in a delay in treatment. Interviews with the LPN and DON confirmed that the treatment was not provided as frequently as recommended and that there was a delay in obtaining the medication. The DON was unaware of both the delay in receiving the cocoa butter and the discrepancy in the frequency of administration compared to the physician's recommendation.