Failure to Follow Physician Orders and Document Wound Care and Medication Administration
Penalty
Summary
The facility failed to ensure that services provided to four out of five sampled residents met professional standards of quality, specifically in the areas of medication administration and wound care. For one resident, there was a physician's order for miconazole powder to be applied daily to the groin, but the medication was not documented as administered for several days, and there was no documentation explaining the omission. The wound care nurse admitted to not entering the physician's order into the electronic medical record (EMR) in a timely manner, which prevented floor nurses from administering the medication as prescribed. Another resident had an active physician's order for daily wound treatment and dressing changes to abrasions on the right hand, but the treatment was not documented as provided on two occasions. Additionally, the order was only updated after the issue was identified during the survey. The resident's care plan required dressing changes and skin treatment per physician's orders, but the documentation did not reflect consistent adherence to these orders. For two other residents, wound care treatments were provided without physician's orders. One resident received wound care to both great toes, and another received wound care to both legs, before the appropriate orders were entered into the EMR. Staff interviews confirmed that wound care was performed and documented in progress notes or paper logs, but not supported by active physician's orders in the EMR at the time of treatment. The director of nursing confirmed that all physician's orders should be entered into the EMR to ensure proper administration and documentation of care.