Failure to Transcribe Physician Orders for Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when the facility failed to transcribe a physician's order for pressure ulcer treatment into the electronic medical records for a resident with a stage four pressure ulcer. The resident, who had diagnoses including a stage four sacral pressure ulcer, stroke with right-sided weakness, and malnutrition, was dependent on staff for activities of daily living. The care plan and physician orders indicated the use of a negative pressure wound vac and dressing changes three times a week, but the physician orders lacked specific details about the type of dressing or treatments to be used. A progress note from a wound nurse practitioner provided detailed instructions for wound care, including cleansing with Dakins solution, applying skin prep and stoma paste, and using a transparent drape and black foam with the wound vac set to negative 125 mmHg. However, these specific orders were not transcribed into the resident's medical record. The facility's wound nurse confirmed that the detailed wound care orders should have been included in the physician orders, and facility policy required that physician orders be transcribed into the electronic medical records.