Incomplete Documentation of Wound Care
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for a resident who was admitted for skilled nursing care following a surgical procedure on the right plantar foot. The resident's clinical record included a physician's order dated December 25, 2024, which specified a wound care regimen to be performed daily during the night shift. However, upon review, there was no documentation in the resident's clinical record to confirm that the wound care was carried out as ordered by the primary care physician. An interview with the facility administrator on January 23, 2025, confirmed the absence of both electronic and written documentation verifying the completion of the prescribed wound care. This lack of documentation indicates a failure to adhere to the physician's orders and maintain accurate medical records, as required by regulatory standards. The deficiency was identified during a review of clinical records and interviews with residents and staff.
Plan Of Correction
The resident no longer resides in the facility. An audit was completed to identify residents with physician orders for wound treatments to ensure accurate documentation. Variances were addressed and recorded on the audit. The licensed nurses were educated on The Wound Treatment Policy with emphasis on adherence to physician's orders and documenting accordingly. DON/Designee will perform 10 random weekly audits for 4 weeks, then monthly for 3 months to ensure that physician's orders are being followed, and wound treatments are being adhered to and documented on. Trends will be reported to the QAPI committee for recommendations as warranted.