Failure to Obtain and Transcribe Admission Wound Care Orders for Resident With Multiple Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to obtain and enter wound care treatment orders upon admission for a resident with multiple existing wounds, contrary to professional standards and the facility’s own wound care policy. The resident, an older male admitted from another nursing facility, had documented diagnoses including orthopedic aftercare following surgical amputation, type 2 diabetes mellitus, and unspecified protein-calorie malnutrition. Discharge records from the sending facility showed active treatment orders for a left below-knee amputation surgical site, an unstageable pressure ulcer on the right heel, a venous ulcer on the right calf, and an arterial ulcer on the right great toe at the time of transfer. On admission, the resident’s care plan identified a wound management problem with a goal for wounds to remain free from infection and an intervention to provide wound care per treatment orders. However, review of the electronic health record for January showed no wound care orders entered, and wound treatment orders did not appear in the record until several days later in February, when a wound care NP assessed the resident and wrote new orders. The wound care NP documented that all wounds were present on admission and that she could tell wound care was being performed based on the condition of the dressings, but there were no corresponding physician orders in the record prior to her assessment. Interviews with facility staff confirmed that admission orders from the discharging facility should have been carried over and entered into the electronic health record on the day of admission. The ADON, DON, NP, wound care NP, and Regional Nurse Consultant each stated that wound care orders should have been obtained or transcribed at admission and that it was the admitting or charge nurse’s responsibility, with oversight by the DON. The facility’s wound care policy required verification of a physician’s order before providing wound care and documentation of wound care in the medical record. Despite this, the resident’s wound care orders were not entered into the electronic health record until several days after admission, resulting in a period during which wound care was being provided without documented physician orders in place.
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