Incomplete Wound Care Order Documentation
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that the medical record for one resident was complete and accurately maintained. Specifically, a physician's order for wound care did not include the location of the wound. Medical record review showed that the resident had a Stage 3 pressure ulcer to the medial sacrum, but the corresponding physician's order for wound care omitted this location detail. During an interview and concurrent record review, the DON confirmed that the wound care order lacked the required wound location information.