Failure to Follow Physician Wound Care Orders Resulting in Infection
Penalty
Summary
The facility failed to follow physician orders for wound care for one resident who was admitted with a leg fracture. The orthopedic physician had ordered that the resident's dressing be removed one week after admission, the incision cleansed with warm water and soap, dried, covered with a nonadhesive pad or gauze, and the dressing changed every one to two days until a follow-up appointment. Staff were also instructed to monitor for signs of infection and contact Trauma/Orthopedics if any were observed. However, the physician's wound care order was not entered into the Treatment Administration Record (TAR), and there was no evidence that the wound care was completed as ordered. As a result, the resident's incision became red, swollen, and warm to the touch, with the resident reporting burning and tenderness. The resident stated that the dressing was not removed for nearly two weeks after admission and that staff did not check the incision until it became infected and painful, despite multiple reports of pain. Staff interviews confirmed that the physician's order was not placed on the TAR, dressing changes were not initiated, and the resident developed an incision infection. The process for entering and verifying new orders was reviewed, and it was acknowledged by multiple staff members that the order was missed.