Failure to Enter Wound Care Orders Upon Admission
Penalty
Summary
A resident with diagnoses including diabetes mellitus, congestive heart failure, and epilepsy was readmitted to the facility with four wounds present on admission. Although a wound assessment report was completed by a nurse practitioner and documented treatment orders for these wounds, a review of the clinical record several days later revealed that no current orders for wound care had been entered. During interviews, a registered nurse confirmed that wound care and dressing changes were being performed without documented orders, and that official orders for dressing changes were only entered several days after the resident's readmission. This failure to ensure that wound treatment orders were entered at the time of admission resulted in a lack of documented physician orders for the resident's immediate wound care needs.