Failure to Implement and Communicate Wound Care Orders
Penalty
Summary
The facility failed to implement ordered interventions for a resident with multiple diagnoses, including left hip fracture, emphysema, respiratory failure, dementia, and moderate protein calorie malnutrition. Specifically, wound care provider orders to off-load wounds and float the resident's heels in bed were not transcribed into the electronic health record (EHR), nor were they incorporated into the resident's care plans or Kardex. As a result, these interventions were not communicated to the Certified Nursing Assistants (CNAs) responsible for the resident's care. Interviews with the Wound Care Nurse and review of documentation confirmed that the orders were not entered or reflected in the care planning tools used by staff. The Director of Nursing (DON) stated that her expectation is for all wound care provider orders to be entered into the EHR and included in care plans, but this did not occur for this resident. Facility policies require that comprehensive care plans include all necessary services and that licensed nursing staff transcribe provider orders according to clinical standards, which was not followed in this instance.