Failure to Transcribe and Implement Admission Wound Care and Nutritional Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that admission orders were properly transcribed and implemented for a newly admitted resident. The resident was admitted from a short-term general hospital with documented diagnoses including peripheral vascular disease, diabetes, and atherosclerosis of native arteries of the extremities with ulceration. The resident’s MDS assessment identified moderately impaired cognition with a BIMS score of 12 and documented seven venous and arterial ulcers present at admission. The hospital transfer summary included specific admission orders for collagenase Santyl ointment to the right heel, betadine to eschar areas on the right foot daily, and Juven nutritional supplement twice daily. Record review showed that the January Medication Administration Record and Treatment Administration Record did not contain documentation of the Juven orders or the wound care treatment orders for the right foot and heel. During an interview, the Interim Director of Nursing acknowledged that she did not properly transcribe the admission orders and missed the wound care and Juven orders. The facility’s policy on Provision of Physician Ordered Services directed staff to provide a reliable process for the proper and consistent provision of physician-ordered services according to professional standards of quality, but the policy did not include guidance on how to transcribe and implement orders.
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