Failure to Document Wound Care Administration or Refusal
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that a resident's medical record accurately reflected whether physician-ordered wound care was implemented or refused. Specifically, for one resident with multiple complex diagnoses, including chronic osteomyelitis, hemiplegia, peripheral vascular disease, and an unhealed, unstageable pressure ulcer, there was no documentation on the Treatment Administration Record (TAR) indicating that wound care was provided or refused on two consecutive days, as required by both physician orders and facility policy. Facility policy required that skin and wound care be documented upon admission, readmission, weekly, and as needed, with each dressing change or at least weekly, including the date and time of treatments. Review of the resident's care plan and physician orders confirmed the need for daily wound care to the left lateral foot. During interviews, facility staff confirmed the absence of documentation for the specified dates and acknowledged that, if care had been refused, this should have been recorded on the TAR but was not.