Failure to Document and Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide and document ordered wound care treatments for a resident with a stage four pressure injury located above the buttocks. Review of the resident's Treatment Administration Records (TAR) for April and May showed that several evening wound care treatments were not documented as completed, specifically on 4/29, 4/30, and 5/10. The wound care nurse confirmed that if wound care is not documented, it is considered not done, and any refusals or absences should be noted in the TAR. The facility's policy requires that the date and time of dressing changes be recorded in the resident's medical record or treatment sheet. At the time of observation, the wound appeared as previously described, with a red wound bed and no active drainage.