Failure to Provide and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring wound care treatment was administered according to physician's routine, PRN, and STAT orders. The physician's order for wound care was incorrectly entered into the Treatment Administration Record (TAR), resulting in the resident not receiving wound care as prescribed. Documentation verifying that wound care was consistently completed was not available, and staff interviews revealed uncertainty about whether the care was provided and properly documented. The resident involved was an older adult male with multiple diagnoses, including pulmonary embolism, rheumatoid arthritis, chronic congestive heart failure, osteoporosis, chronic pain syndrome, and a chronic left foot ulcer. Upon admission, the resident had a stage 3 pressure ulcer on the sacrum and was receiving antibiotics via a PICC line for sepsis related to his wound. The care plan included interventions for skin integrity and wound care per physician orders, but there was no documentation to confirm that these interventions were carried out as ordered. Interviews with the DON, RN, and Medical Record Director indicated that the wound care order was not properly entered into the TAR, and there was no documentation of wound care being completed for the resident. The DON acknowledged responsibility for reviewing orders but stated that the transition between DONs led to a lapse in order review. The facility's policy required complete and clear documentation of physician orders and prompt, accurate transcription by nursing staff, but these procedures were not followed in this case.