Failure to Implement Surgical Wound Care Orders Upon Admission
Penalty
Summary
A deficiency occurred when a resident admitted with a diagnosis including sepsis due to Serratia did not receive surgical wound care as directed in the hospital's continuity of care document. The discharge instructions specified that the resident's left hip incision site should be cleansed with Vashe cleanser, patted dry, and covered with an antibacterial dressing and protective cover daily and as needed. Although these instructions were provided to the facility upon admission, there was no evidence that a physician's order for the wound treatment was implemented until three days after admission. Staff interviews confirmed that the surgical wound care instructions were present in the admission documentation but were not acted upon until several days later. The Unit Manager acknowledged the delay, and the Nurse Practitioner stated that the treatment order should have been implemented upon admission. The DON was unable to provide evidence that the wound care order was carried out as required during the initial days following the resident's admission.