Failure to Transcribe and Implement Surgical Wound Care Orders on Admission
Penalty
Summary
The facility failed to initiate and transcribe physician orders for the care of a surgical wound upon admission for a resident who had recently undergone a total left knee replacement. Hospital discharge instructions specified that the Aquacel dressing should remain in place for seven days post-surgery, after which it should be removed and replaced with a dry dressing if needed, and that a Zipline dressing should be removed fourteen days postoperatively. Upon admission, the resident's skin assessment noted the presence of the Aquacel dressing but did not specify the presence of surgical clips or a Zipline dressing. There were no corresponding physician orders on the August MAR/TAR for the removal of either dressing as outlined in the hospital discharge summary. Interviews and record reviews confirmed that the required wound care orders were not present or transcribed into the facility's records. The resident reported repeatedly asking nursing staff about the removal of the dressings but did not receive a response. The outer Aquacel dressing was reportedly removed on the seventh postoperative day, but the Zipline dressing was not removed during the resident's stay and was only removed after discharge by a home health therapist. The discharge nursing note and instructions also failed to document or communicate any ongoing surgical wound care needs. Facility leadership, including the DON and Medical Director, confirmed that the hospital discharge summary contained clear instructions for wound management, which were not transcribed into the facility's orders or care records. The admitting nurse did not ensure the surgical wound orders were carried over, and there was no evidence that the physician or nurse practitioner reviewed or approved the discharge summary prior to admission. The lack of proper transcription and follow-through resulted in the omission of necessary wound care interventions during the resident's stay.