Inaccurate Documentation of Wound Care by Agency LPN
Penalty
Summary
A deficiency occurred when an agency LPN documented that a prescribed wound treatment for a resident with paraplegia, diabetes mellitus, and two stage four pressure ulcers had been completed, when in fact the treatment was not performed. The resident, who was cognitively intact, reported that the evening shift did not complete the treatment on her pressure areas, despite the Treatment Administration Record showing the LPN's initials indicating completion. The resident informed the night shift nurse, who confirmed the treatment had not been done and subsequently completed it. Record review showed physician orders for specific wound care, including the application of BNZ cream and various wound dressings to the sacral area, to be performed twice daily. During interviews, it was confirmed by another agency LPN that the treatment had not been completed as documented, and the lapse was not communicated during shift report. The Director of Nursing stated that the agency LPN responsible would not return to work at the facility.