Wound Care Treatment Not Completed as Documented
Penalty
Summary
A deficiency occurred when a licensed nurse signed off on a wound care treatment for a resident in the electronic health record, indicating it was completed, when in fact the treatment had not been performed. The resident, who had diagnoses of depression, diabetes mellitus, and severely impaired cognition, required daily wound care for venous stasis ulcers on both lower extremities as ordered by the physician. Observations revealed that the resident had removed her own dressing in the dining room, exposing a wound with serosanguineous drainage, and left the soiled dressing and wraps on the table. Multiple staff members walked by without intervening, and the dressing remained off for several hours. Further review and interviews confirmed that the nurse responsible for the treatment had not completed the wound care as ordered, despite documenting it as done in the medical record. The nurse admitted to signing off the treatment before it was performed due to being busy with other tasks and not being aware that the resident had removed her dressing earlier in the day. Facility policy required that services provided be accurately documented, including the date, time, and signature of the person recording the data. This failure to provide wound care as ordered and to accurately document services placed the resident at risk for delayed healing and infection.