Failure to Document Wound and Catheter Care in Accordance with Professional Standards
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. Specifically, nursing staff did not document wound care and catheter-related interventions for residents with significant medical needs. On two separate dates, there was no documentation of wound care for open areas on the right and left buttocks for both residents, nor was there documentation of catheter care, including the use of a privacy bag, catheter securement device, and the presence of a 16 French catheter to bedside drainage. Resident 2, a male with hemiplegia and prostate cancer, had care plans and physician orders requiring daily wound care for moisture-associated skin damage and regular catheter care. Resident 4, a female with right-side hemiplegia and aphasia, also had orders for wound care to multiple areas on her buttocks. Despite these orders, the treatment administration records for both residents showed missing documentation for the required care on the specified dates and shifts. Interviews with the involved RNs and LVNs revealed that while they stated the care was provided, they admitted to forgetting to document the interventions due to being called away or becoming busy. The Acting DON confirmed that documentation was expected to be completed accurately and acknowledged that the errors were due to staff not paying attention and failing to document their work. Facility policy required immediate documentation of treatments and review of records before the end of each shift, which was not followed in these instances.