Failure to Accurately Document Wound Care for a Resident
Penalty
Summary
The facility failed to ensure accurate documentation of wound care for a resident with multiple wounds, as required by physician orders and professional standards. Review of the Treatment Administration Records (TAR) for the resident revealed multiple dates across June and July where wound care treatments for various sites—including the right and left ischial areas, right heel, right posterior thigh, left posterior thigh, and coccyx—were not documented. Physician orders specified detailed wound care regimens for each site, but there were no entries on several specified dates, indicating either the care was not provided or not recorded. Interviews with staff confirmed that documentation was missing and that refusals by the resident were not recorded, despite the resident stating they did not refuse care. Further interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the wound care nurse revealed inconsistencies in the process for reporting and documenting wound care, especially when performed by night shift nurses. The wound care nurse acknowledged gaps in the TAR and a lack of consistent communication or reporting from night shift staff regarding missed wound care. The DON confirmed the expectation that wound care should always be documented, and the ADON noted that refusals should have been documented if they occurred. The absence of documentation on the TAR for the specified dates led to the deficiency finding.