Missed Physician-Ordered Wound Care Due to Documentation and Communication Failure
Penalty
Summary
A resident with multiple complex medical conditions, including diabetes mellitus, bullous pemphigoid, diabetic ulcers, bipolar disorder, and obsessive-compulsive disorder, was admitted with physician orders for specific wound care treatments to be performed three times a week and as needed. The resident had a documented history of refusing wound care from nurses other than a specific treatment nurse. On one occasion, the Treatment Administration Record (TAR) showed a blank entry, indicating that the prescribed wound care was not provided on that day. There was no documentation that the resident refused care on that date, and the facility's policy required notification of the supervisor if a resident refused a dressing change. Interviews with nursing staff and the Director of Nursing confirmed that the wound care was missed on the identified date, with staff attributing the lapse to a treatment nurse calling off work and the charge nurse providing care instead. However, there was no record of the resident refusing treatment or any documentation explaining the missed care. The facility's policy also required reporting of refusals and other relevant information, which was not followed in this instance.