Failure to Provide Physician-Ordered Wound Care Treatment
Penalty
Summary
The facility failed to provide wound care treatment as ordered by the physician for one resident with a cervical incision. According to the facility's wound treatment management policy, wound treatments are to be performed in accordance with physician orders and documented in the Treatment Administration Record (TAR) or electronic health record. The resident, who had a history of spinal fusion, hypertension, and falls, had a physician order for daily cleansing of the cervical incision with normal saline, application of calcium alginate Ag, and covering with a border dressing. Review of the TAR for September showed that the required wound treatment was not documented as completed on two specific dates, and there was no further documentation in the electronic record to indicate the treatment was provided on those days. The Director of Nursing confirmed that the treatment was not completed as ordered.