Failure to Document Wound Care Treatments
Penalty
Summary
The facility failed to provide documented evidence that wound care treatments were administered according to the physician's orders for one resident. This resident, who was admitted with diagnoses including type 2 diabetes mellitus with circulatory complications, a stage 3 pressure ulcer in the sacral region, and atrial fibrillation, had a physician's order for specific wound care treatment. The order required cleansing the wound with normal saline, applying Medihoney and Triad cream, and covering it with gauze daily. However, the Treatment Administration Record (TAR) lacked documentation of these treatments being completed from March 25, 2025, through March 31, 2025. Interviews with the Wound Care Nurse and the Director of Nursing (DON) confirmed the absence of documentation for the wound care treatments during the specified period. The Wound Care Nurse explained that the Admission Nurse was responsible for the initial skin assessment, while the wound care staff was to perform further assessments and obtain treatment orders. The DON stated that staff were expected to document treatments on the TAR. The facility's policy on pressure ulcer prevention required licensed nurses to record the condition of the skin and the treatment provided, which was not adhered to in this case.