Failure to Transcribe and Provide Ordered Surgical Wound Care on Admission
Penalty
Summary
The deficiency involves the facility’s failure to transcribe and implement a physician’s order for surgical wound care upon admission, resulting in the absence of ordered treatment for a resident’s abdominal incision. The resident was admitted following an exploratory laparotomy with creation of a colostomy related to diverticulitis with perforation. The hospital discharge summary documented that on the day of discharge the physician opened a 4 cm portion of the wound below the umbilicus due to seropurulent drainage and ordered wet-to-dry dressing changes with normal saline twice daily. Review of the admission physician orders and the Treatment Administration Record for the admission and following day showed no orders for wet-to-dry dressings or any surgical wound care. The resident’s discharge MDS later documented discharge to home/community with return not anticipated. Nurse #1, who admitted the resident, stated she reviewed the hospital discharge summary only for medication orders and did not read the entire summary, resulting in failure to transcribe the wound care order to the TAR. She reported having a very busy day and acknowledged that between herself and the DON, the treatment order should have been entered. The DON confirmed she assisted with the admission, entered medication orders, assessed the incision, and skimmed the discharge summary, recognizing later that she had not seen incision care orders and then forgot to recheck the summary. Nurse #2 and Nurse #3, who cared for the resident on subsequent shifts, recalled the resident and his new colostomy but indicated they would need to review the record to identify any treatment orders; Nurse #3 confirmed she assessed the incision but did not provide treatment. The Physician Assistant stated nurses are expected to read the entire discharge summary for all discharge orders and that, in the absence of incision care orders, the facility should have contacted him for interim orders.
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