Failure to Follow and Document Wound Care and PRN Pain Medication Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide and document wound care and pain medication in accordance with physician orders and professional standards for one resident. The resident had normal cognition and diagnoses including severe life-threatening blood infection, diabetes, and a rare flesh-eating bacterial infection, with an open lesion requiring wound management. A verbal order was obtained for wet-to-dry dressing changes twice daily to the perianal wound, with packing and appropriate dressings, and this order was signed and entered into the physician orders. The resident’s care plan included wound management interventions such as regular wound measurements, monitoring for infection, and wet-to-dry dressing changes twice daily. However, the progress notes did not contain the verbal order received earlier in the day, and the Treatment Administration Record showed multiple missing entries for the ordered wound treatments on several days, despite staff and the DON acknowledging that at least some treatments were performed. The Medication Administration Record showed an order for oxycodone/APAP 5-325 mg, one tablet twice daily as needed, but the resident received three doses in a single day, exceeding the ordered frequency. Staff interviews revealed that RNs were aware of issues with orders not populating to the TAR and that one RN knew wound treatment orders were missing from the TAR but did not enter them, even though she provided a wet-to-dry dressing based on verbal instruction. Another RN stated she entered the dressing change order but it did not populate to the TAR until she later corrected it. The DON and Administrator both acknowledged that wound treatments were not documented on the TAR for specified days and that the resident should not have received three doses of oxycodone when ordered for two. Facility policies on medication administration and documentation required that medications be administered per physician orders and that all new orders, including wound care, be documented in the nurse’s notes with details of the treatment and wound appearance, which did not occur in this case.
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