Failure to Transcribe and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure that wound care treatment orders for a resident were appropriately transcribed and implemented according to physician instructions. The resident, who had multiple diagnoses including peripheral vascular disease, diabetes, and a recent diagnosis of cellulitis, was assessed by the Wound Doctor, who ordered daily dressing changes and specific wound care interventions for venous insufficiency ulcers on both lower legs. However, these orders were not transcribed into the electronic Physician Order Sheet (ePOS) or the Medication Administration Record (MAR), and there was no documentation of the wounds in the resident's care plan. Observations revealed that the resident had visible wounds on both legs, which were not covered with dressings or compression socks as ordered. The resident reported having wounds for one to two months and stated that a doctor had prescribed medication nine days prior, but the treatment had not been received. Interviews with staff indicated confusion regarding responsibility for transcribing and implementing physician orders, with the desk nurse responsible for order entry but failing to transcribe the wound care orders into the electronic medical record. The Director of Nursing was unaware of the new wound care orders, and the LPN involved stated that only an order for the resident to be seen by the Wound Doctor had been entered. The Wound Doctor confirmed that he expected his orders to be followed and that the treatments he prescribed had not been administered. This sequence of events resulted in the resident not receiving necessary wound care as ordered by the physician.