Failure to Complete and Document Wound Care and Assessment
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including metabolic encephalopathy, type 2 diabetes mellitus, cellulitis, open wounds to both lower extremities and right foot, peripheral vascular disease, and congestive heart failure, did not receive wound care in accordance with physician orders and facility policy. The Treatment Administration Record (TAR) for this resident showed blank entries on specific dates, indicating that wound care treatments were not completed or documented. On one occasion, a code indicating 'other/see nurse's notes' was used, but no corresponding nurse's note was found to explain the omission. Multiple staff interviews confirmed that a blank TAR entry means the treatment was not completed, and a code requires a progress note, which was missing. Additionally, after the resident returned from a hospital stay, a full assessment of the resident's non-pressure wounds was not completed as required. The admission/readmission evaluation documented the presence of multiple open areas and significant edema, but staff, including the Assistant Director of Nursing and Director of Nursing, acknowledged that a comprehensive wound assessment should have been performed upon readmission. These actions and omissions were not in accordance with professional standards of practice, the resident's care plan, or facility policy.