Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate for a resident with multiple wounds, including a stage 3 pressure ulcer on the left buttock and stage 1 pressure ulcers on both heels. Physician orders specified detailed wound care regimens, including cleaning, application of honey to calcium alginate, covering with optifoam dressing on specific days, and the use of heel protectors while in bed. Additional orders included daily skin prep for both heels. A review of the treatment administration record for the month revealed missing documentation for several ordered treatments. Specifically, there was no documentation of the left buttock wound care on two ordered days, nor documentation of the left and right heel treatments and heel protector intervention on another day. During an interview, the DON confirmed that while audits had been conducted to verify wound treatments were completed, these audits did not focus on whether the treatments were properly documented as completed in the records.