Incomplete Documentation of Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that medical record documentation was completed and accurate for a resident with a pressure ulcer. The resident, who was admitted with metabolic encephalopathy, type 2 diabetes mellitus, and unspecified diarrhea, had an unstageable pressure ulcer present on admission. The care plan required weekly treatment and measurement of all areas of skin breakdown. However, a review of the Treatment Administration Record (TAR) for June showed missing documentation for several days, specifically 6/1, 6/2, 6/4, and 6/9, regarding whether the prescribed wound care was provided. During interviews, an LPN confirmed that she performed the wound treatment on one of the missing dates but did not document it due to being distracted. She acknowledged being trained to document treatments after completion. The facility administrator stated that the expectation was for all treatments to be documented after they are completed. The lack of documentation resulted in incomplete medical records for the resident's pressure ulcer care.