Failure to Enter and Review Wound Care Orders Upon Admission
Penalty
Summary
The facility failed to ensure that a physician or provider reviewed and entered all necessary orders for a resident upon admission, specifically omitting wound care orders for a resident with multiple complex medical conditions. The resident was admitted with diagnoses including acute osteomyelitis of the left ankle and foot, cutaneous abscess of the left foot, diabetes with chronic kidney disease, and end stage renal disease. Hospital discharge orders included instructions for wound care and evaluation by a wound care team, but these were not entered into the facility's physician orders upon admission. A review of the resident's physician orders revealed that there were no orders to monitor or provide wound care for any existing wounds from the day of admission until the resident was discharged. During interviews, the physician assistant recalled the resident and his wounds but was unaware that no wound care orders had been entered during the resident's stay. The physician assistant stated that it was standard for facility nurses to contact her to review and approve admitting orders, but she could not recall being contacted about this admission or reviewing the orders for this resident. The deficiency was identified when it was found that the resident did not have wound care orders in place during their stay, despite having wounds that required treatment. The lack of review and entry of necessary orders by the provider resulted in the resident not having documented wound care provided as directed by the hospital discharge instructions.
Removal Plan
- Initiate a new admit audit to ensure all tasks and admissions items are complete and confirmed during the stand down process.
- Update the wound care order verification process.
- Educate the team on the new clinical review protocol, including notification of the IDT team when a resident is admitted with wounds.
- Unit manager or designee to review orders with the provider for new admissions with wounds.
- Contact NExcell provider if an admitting wound is considered complex or needs additional oversight.
- Hold wound care meetings by the IDT team to ensure process is followed and all orders are entered appropriately, care plans are updated and accurate, and wound pictures are taken.
- Conduct whole house skin sweep audits to identify any undocumented wounds.
- Confirm all treatment orders are in place and accurate.
- Audit all care plans to ensure accuracy per wound orders.
- Re-educate direct care staff on wound documentation and inputting orders upon admission.
- Re-educate Center Nurses on completion of skin assessments.
- Educate nurses on responsibility for communication with management and provider for change in condition process/documentation, including new or worsening wounds.
- Educate nurses on Genesis wound processes, including DIMES, identification and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation.
- Educate CNAs on the change in condition process for CNAs (including skin changes) and stop and watch.
- Ensure 100% of available staff have been educated on these processes, with any unscheduled staff to be educated prior to their next shift.
- Director of Nursing/Designee to audit education sign-off sheets to ensure all nursing staff receive the required education.
- Director of Nursing/Designee to conduct random audits of residents with wounds for skin assessment, order accuracy, and wound care process abidance.
- Bring audit results to the QAPI committee for tracking, trending, and further recommendations.
- Administrator to oversee the QAPI committee.