Failure to Document and Communicate Wound Care Assessments
Penalty
Summary
The facility failed to ensure proper communication and documentation regarding wound care for a resident with type II diabetes and a right ankle abrasion. Physician orders for wound care changed multiple times over several months, specifying different treatments and dressing protocols. However, after a wound assessment on 4/17/25, there was no further documentation of wound assessments, measurements, or wound appearance in the clinical record, despite ongoing care and weekly visits to a hospital wound care center. The facility's records did not include wound care notes or reports from the hospital wound care center, and these documents were not scanned into the resident's clinical record for staff access. Interviews revealed that staff were unaware of the current status and treatment details of the resident's wound, relying instead on information from the resident's family. The LPN indicated that nurses could not access wound center reports and were not informed of wound measurements or treatments provided by the wound care center. The Regional Director of Clinical Operations confirmed that no staff member was responsible for scanning external wound care documents into the record after the medical records staff left the facility. As a result, there was a lack of communication and documentation between the facility and the external wound clinic, leading to incomplete records and potential gaps in care.