Failure to Transcribe Physician's Wound Care Order to Administration Records
Penalty
Summary
Facility staff failed to follow professional standards of practice for one resident by not properly transcribing a physician's order for wound care treatment. Specifically, a physician's order dated 5/2/25 directed that the resident's sacral wound be cleansed with normal saline, patted dry, and covered with a foam dressing. Upon review of the resident's clinical record, it was found that this order was not present on the medication administration record (MAR) or the treatment administration record (TAR) for May 2025. Interviews with staff revealed that the nurse who entered the order into the computer system did not select a schedule for the treatment, resulting in the order not being carried over to the MAR or TAR. The facility's policy requires that all medication and treatment orders be completely transcribed onto the appropriate administration records. The deficiency was confirmed through staff interviews and review of facility documentation.