Failure to Document Wound Care Treatment for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to accurately document wound care treatment for one resident with a stage 4 pressure ulcer. The resident, who had a history of paraplegia, neuromuscular bladder dysfunction, and a stage 4 pressure ulcer on the right buttock, was admitted and readmitted to the facility with these diagnoses. Physician orders indicated daily wound care treatment for the pressure ulcer, and the treatment was to be documented in the resident's medical record. However, from 5/14/2025 to 5/27/2025, there was no documentation in the medical record to confirm that the wound care treatment was provided, despite the treatment nurse stating that the care was given during this period. Record reviews showed that the last documented wound care was on 5/13/2025, and subsequent treatment records were missing for the following 14 days. The facility's policy required that all treatments be documented upon completion, but this was not followed. Both the treatment nurse and the Director of Nursing confirmed that the required documentation was not completed, resulting in a lack of proof that the prescribed wound care was administered during the specified period.