Failure to Obtain and Implement Physician Order for New Wound Treatment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received treatment and care in accordance with professional standards and physician orders. The resident, who had a history of spina bifida, constipation, and urinary retention, was identified as having a new wound on their back during a hospital wound care consult. The consult provided specific instructions for wound care, including the use of Triad ointment and Alginate AG dressings, to be applied three times per week for fifteen days. However, there was no documented evidence that a physician order for the treatment of this new wound was obtained or entered into the facility's system. Record reviews showed that the physician order report, treatment administration record, and medication administration record did not contain any orders or documentation for the treatment of the new back wound. Additionally, nursing progress notes did not mention the new wound, and the care plan only referenced existing wounds and general approaches, such as reporting skin changes and providing wound care as ordered. Interviews with facility staff, including the Assistant DON and DON, confirmed that the new wound was not identified by the facility and that there was a delay in receiving the consult note from the hospital wound care clinic. The consult note was faxed to the facility several days after the resident's return, and the process for entering new orders was not completed in a timely manner. Staff interviews further revealed that the usual process involved receiving paperwork from the outside wound care consult, which would then be given to nursing leadership for order entry and scanning into the system. In this case, the consult note was not immediately available, and the new wound and its required treatment were not addressed until the documentation was received and reviewed days later. This lapse resulted in the resident not having a physician order or documented treatment for the new wound as required by professional standards and facility policy.