Failure to Initiate and Provide Ordered Surgical Wound Care
Penalty
Summary
Facility staff failed to provide ordered surgical wound care for one resident following admission. The facility’s new/re-admission process required a licensed nurse to review admission orders and input wound treatment orders into the system. The resident was admitted with a diagnosis of encounter for surgical aftercare following surgery on the circulatory system. The hospital after visit summary (AVS) included detailed wound care orders for the left fourth toe, specifying cleansing with soap and water, application of povidone (Betadine), placement of gauze between each toe space and in the crease of the fifth toe, and use of a Rooke boot, to be performed twice daily. Record review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed that the wound care order from the AVS was not activated on the TAR until several days after admission, and no wound care was charted during that period. Interviews with the Interim Director of Nursing and the Director of Nursing confirmed that staff should have used the wound care orders from the AVS and that the wound care was not initiated or completed during the identified dates.
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