Failure to Document Wound Care in Medical Record
Penalty
Summary
The facility failed to document wound care treatment provided to one resident in the Treatment Administration Record (TAR) as required by professional standards and facility policy. The resident was admitted with multiple diagnoses, including type 2 diabetes, alcoholic cirrhosis of the liver, dysphagia, chronic kidney disease, an unstageable pressure ulcer of the sacrum, and a gastrostomy tube. Physician orders directed daily wound care for both the sacrum and gastrostomy tube site. However, review of the TAR for the relevant period showed that documentation of these treatments was left blank for several days. Interviews with the licensed vocational nurses responsible for the resident's care confirmed that the treatments were provided as ordered, but the nurses did not document the completion of these treatments in the TAR. The Director of Nursing also acknowledged that documentation should have occurred after the treatments were provided, in accordance with facility policy, which requires that care and services be documented at the time of service or by the end of the shift.