Failure to Accurately Document Wound Care Treatments
Penalty
Summary
The facility failed to maintain accurate documentation of wound care treatments for two residents, as required by its own policy and accepted professional standards. For one resident with a sacral pressure ulcer and significant physical and cognitive impairments, the Treatment Administration Record (TAR) was left blank and not signed for a scheduled wound care treatment. The physician's order specified daily dressing changes, but the lack of documentation on the TAR for a specific date resulted in an incomplete medical record for the care provided. For a second resident with multiple pressure ulcers at various stages and severe cognitive impairment, the TAR was not signed for several wound care treatments on two separate days. The physician's orders detailed specific wound care procedures for multiple sites, but the TAR lacked the initials of the nurse responsible for administering these treatments. During interviews, the nurse who provided the care confirmed that the treatments were performed but not documented at the time, and the Director of Nursing acknowledged that the TAR should have been signed immediately after care was provided. The facility's policy on charting and documentation requires that all services provided to residents be documented in an objective, complete, and accurate manner, including the date, time, and name of the individual providing care. The failure to document wound care treatments as required resulted in medical records that did not accurately reflect the care provided to the two residents.