Failure to Document Daily Wound Care for Pressure Ulcers
Penalty
Summary
Facility staff failed to document the delivery of daily wound care for residents with pressure ulcers, as evidenced by a review of medical records and treatment administration records (TARs) for two residents. One resident, observed with specialized heel protectors, had a physician order for daily wound care to the left heel, but the TAR showed no documentation of treatment on several specified dates. The Director of Nursing (DON) confirmed the absence of documentation for these dates and acknowledged that wound care should be signed or initialed when performed. A second resident, who had physician orders for daily wound care to the right heel and sacrum, also had missing documentation in the TAR for multiple dates across two months. The DON reviewed the records and confirmed that there was no documentation for the required wound care on the specified dates for both the right heel and sacral wounds. No additional documentation was provided by the facility at the time of the survey exit.