Failure to Transcribe Non-Weight Bearing Order for Resident with Diabetic Foot Ulcer
Penalty
Summary
A deficiency occurred when a non-weight bearing order for a resident's right foot, as prescribed by the wound care specialist, was not transcribed into the resident's electronic health record. The resident, who was admitted with diagnoses including osteomyelitis, type-2 diabetes mellitus, and hypertension, had moderately impaired cognition and required significant assistance with activities of daily living. The resident also had diabetic foot ulcers requiring wound dressings. During review, it was found that the wound care specialist's visit note documented the non-weight bearing order, but this order was not entered into the resident's active orders. Interviews with the RN and DON revealed that the process for handling new orders involved verbal and written communication from the wound care specialist to the treatment nurse, who was responsible for entering the orders. Additionally, the medical records and QA nurse were expected to review the wound care notes and notify nursing staff of new orders. Despite these procedures, the non-weight bearing order was not transcribed, resulting in the absence of this critical instruction in the resident's care plan.