Failure to Clarify and Follow Physician Orders for Wound Care and Urine Testing
Penalty
Summary
The facility failed to clarify a physician's order regarding surgical dressing care for one resident. The resident was admitted with an order stating that an Aquacel dressing should have been removed on a specific date and the incision left open to air. However, upon arrival at the facility several days later, the Aquacel dressing was still intact, indicating that the order was not followed or clarified as required by facility policy. The Director of Nursing confirmed that the conflicting orders should have been clarified with the physician. Additionally, the facility did not follow a physician's order to obtain a urinalysis and culture & sensitivity (UA C&S) in a timely manner for another resident. The order was written for the test to be performed due to symptoms of dysuria and frequency, but the urine sample was not collected until several days after the order was given. The clinical record lacked evidence that the test was collected promptly, as required by the physician's instructions.