Failure to Implement and Document Physician Wound Care Orders
Penalty
Summary
A resident with a diagnosis including basal cell carcinoma was admitted to the facility and subsequently underwent MOHS surgery to remove skin cancer. Following the procedure, a dermatologist provided specific wound care orders, including daily soaks with a white vinegar and water solution and the application of Manuka Honey to raw areas on the face and neck twice daily until healed. These orders were documented on a Continuity of Care Consultation and Referral Form. Record review revealed that from September through November, there was no evidence in the Treatment Administration Records (TAR) that the dermatologist's wound care orders were implemented. There was also no documentation indicating that the facility physician had declined or verified the dermatologist's orders. During an interview, the Administrator was unable to provide evidence that the orders were followed or that any verification or declination by the facility physician had occurred.