Failure to Document and Provide Ordered Wound Care Treatments
Penalty
Summary
The facility failed to ensure that a resident received wound care treatments as ordered by the physician and in accordance with the resident's care plan and preferences. Documentation was lacking for multiple wound care treatments, with several instances where treatments were not recorded on the Treatment Administration Record (TAR) and no progress notes indicating whether the resident refused care. The care plan required staff to monitor, document, and report on the resident's skin integrity and wound care, but these interventions were not consistently documented or followed. The resident involved had a history of psychiatric diagnoses, including major depression and schizophrenia, and was noted to have intact cognitive status. She frequently refused care, including wound care, bathing, and other activities of daily living. Multiple staff interviews confirmed that the resident often declined assistance and that staff made repeated attempts to provide care, sometimes involving family members to encourage cooperation. Despite these refusals, staff did not consistently document the refusals or the care provided, as required by facility policy and physician orders. Facility leadership, including the DON, administrator, and VP of Clinical Operations, confirmed that all ordered treatments should be completed and documented, and that refusals should be recorded in both the TAR and progress notes. The facility's documentation policy required timely and complete entries in the electronic health record, but review of records showed gaps in documentation for wound care treatments. This lack of documentation and failure to follow professional standards of practice led to the deficiency cited in the report.