Failure to Document Wound Care Treatments in Medical Records
Penalty
Summary
The facility failed to ensure that medical records were maintained in accordance with professional standards and were complete and accurately documented for one resident. Specifically, on two occasions, wound care treatments provided to a resident with quadriplegia, morbid obesity, type 2 diabetes, neurogenic bowel, and multiple wounds were not documented in the Treatment Administration Record (TAR) or Licensed Nurse Administration Record (LNAR) as required by facility policy. The resident's care plan included interventions for fragile skin and actual wounds, with physician orders for specific wound care treatments. However, review of the April TAR and LNAR revealed blanks for the required wound care treatments on the specified date, and there was no documentation in the progress notes for those treatments. Observation confirmed that a nurse performed the required wound care treatments, but interviews with nursing staff and administration revealed that documentation was expected to be completed immediately after treatment. The nurse involved stated she had documented the treatments, but the records did not reflect this. Facility policy required documentation of wound care in the TAR, and the absence of such documentation indicated non-compliance with professional standards and facility policy.