Failure to Follow Physician Orders and Document Wound Care Treatments
Penalty
Summary
The facility failed to follow physician's orders and ensure proper documentation of treatments for a resident with venous ulcers and lymphedema. Staff were observed not changing the resident's dressings as ordered, and the dressings present were unlabeled. The resident had orders for daily wound care and the use of compression stockings or TED hose, but staff confirmed that these were not applied and that the required wound care was not performed as documented. The nurse responsible admitted to documenting the treatment as completed in the Treatment Administration Record (TAR) before actually performing the care, and also stated that the resident had never worn the prescribed compression stockings or TED hose. Interviews with the Resident Care Manager and Director of Nursing Services confirmed that staff are expected to follow physician orders, label dressings with initials and date, and only document treatments after they are completed. The review of facility policy also supported these expectations. The failure to follow these procedures was confirmed through observation, interview, and record review, and was found to be inconsistent with both facility policy and professional standards.