Failure to Follow and Transcribe Physician Wound Care Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and provide ordered wound care for a cognitively intact resident with multiple complex medical conditions, including atrial fibrillation, heart failure, osteomyelitis, type 2 diabetes, and several pressure and non-pressure wounds. Record review showed multiple physician orders for wound treatments to the coccyx, sacrum, mid-thoracic back, back incision, bilateral heels, and right heel over December, including specific cleansing solutions, topical agents (such as Santyl and miconazole), dressings (calcium alginate, silicone border foam, ABD pads, mepilex), and treatment frequencies. The December treatment administration record (TAR) revealed that several of these ordered treatments were not signed off on multiple dates, including coccyx treatment, sacral wound care, mid-thoracic back wound care, miconazole powder applications, right heel dressing changes, back incision care, and bilateral heel protection. Wound documentation from mid-December indicated that the mid-thoracic, sacral, and bilateral heel wounds were improving from admission, but the missing documentation on the TAR showed that ordered treatments were not consistently documented as provided. Further review of the after-visit summary dated early January showed new orders to pack the coccyx wound with Dakin’s-soaked kerlix and apply sacral foam, to paint bilateral heels with iodine and cover with mepilex daily, and to check the back incision dressing at least once per shift and change it on postoperative day three and as needed thereafter. However, these orders were not fully transcribed into the physician orders: there was no order entered for monitoring the back incision every shift or for changing the postoperative dressing on the specified postoperative day, and no sacral wound treatment order was present from the time of the after-visit summary until several days later. Heel inspection orders were present but not signed off on at least one date in January, and an order to paint the left heel with betadine and cover with mepilex was not started until after the resident’s discharge. During interview, the Administrator confirmed that the discharge orders for sacral packing, bilateral heel care, and back incision monitoring and dressing changes were not fully entered into the physician orders, that an order for the back incision dressing placed under “other” did not appear on the physician order list, and that there were gaps in sacral and heel treatment orders and multiple wound treatments not signed off in December, contrary to the facility’s wound treatment management policy requiring wound care in accordance with physician orders and prompt physician notification when orders are absent.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.