Failure to Document Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to ensure accurate and complete documentation of wound care treatments for three residents with pressure ulcers. For one resident with multiple chronic conditions, including congestive heart failure and peripheral vascular disease, there was no documentation on the Treatment Administration Record (TAR) for several dates when wound care was ordered. Another resident with diabetes and a chronic venous ulcer also had missing documentation on the TAR for multiple dates in both May and June, despite physician orders specifying wound care on certain days. A third resident with a history of diabetic foot ulcer and other chronic illnesses similarly had gaps in documentation for ordered wound treatments. The facility's policy required that wound treatments be documented at the time of each treatment, and if no treatment was due, the status of the dressing should be recorded each shift. However, review of the TARs showed that documentation was not consistently completed as required. The Director of Nursing confirmed that, although nurses were performing the treatments, they were not documenting them on the TARs, leading to incomplete medical records for these residents.