Inaccurate Treatment Administration Records for Pressure Ulcer Care
Penalty
Summary
The facility failed to maintain accurate and complete treatment administration records (TAR) for one resident with a history of Parkinson's disease, bipolar disorder, and muscle weakness, who was admitted in 2010. During an interview, the resident reported that his dressing for a pressure ulcer had not been changed the previous day or on the day of the interview, and that staff did not regularly reposition him or use heel protectors as ordered. Observation confirmed the resident was lying on his back without heel protectors, and he stated that repositioning only occurred during dressing changes, not daily as required. Upon review of the resident's TARs for March and April, two different versions were provided by the facility on consecutive days. The initial TARs showed multiple unsigned entries for required treatments, including application of an abdominal binder, heel protectors, and repositioning every two hours. The subsequent TARs had these previously blank areas filled in and signed. The Director of Nursing acknowledged the discrepancies and the presence of unsigned days in the original TARs. Clinical notes from the nurse practitioner indicated the resident's sacral pressure ulcer was deteriorating during this period. Facility policy requires that all treatments and services performed be documented objectively, completely, and accurately in the medical record.