Failure to Timely Implement and Follow Wound NP Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow and timely implement wound care orders for a cognitively intact resident with diagnoses including DVT and diabetes, who was admitted with an arterial ulcer on the left heel. On admission, a wound NP ordered the ulcer to be cleansed with wound cleanser or normal saline, betadine applied, covered with an abdominal pad, and lightly wrapped with rolled gauze twice daily; however, the ETAR for September and October showed the order entered and carried out only once daily. A subsequent wound NP note changed the treatment to cleansing with wound cleanser or normal saline, application of Santyl, and coverage with an abdominal pad and rolled gauze daily, but the ETAR showed this new order was not initiated until five days later. Later, the wound NP ordered the same ulcer to be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, Dakins-moistened fluffed gauze applied, and covered with a silicone bordered superabsorbent dressing twice daily. The November ETAR reflected a physician order for this treatment only once daily from early to mid-month, and it was not changed to twice daily until several days after the NP’s order. Interviews revealed that wound treatments were documented in the ETAR and blanks indicated missed treatments, and that the ADON waited one to two days after the NP’s visit to receive a report and then transcribe new orders, without going through the resident’s primary physician. Facility policy required that all physician orders received be implemented and followed as they are received, but the wound NP’s treatment orders were not promptly or accurately reflected in the resident’s treatment records.
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