Failure to Complete and Accurately Document Dressing Changes
Penalty
Summary
A deficiency occurred when a resident with a history of diabetes, Parkinson's disease, and heart disease, who was cognitively intact, did not receive dressing changes for a skin tear as ordered. The resident was observed with a gauze dressing on his left wrist dated five days prior, and he reported that it had been a couple of days since the dressing was last changed. The treatment order specified that the wound should be cleansed, antibiotic ointment applied, and a dry dressing placed every day shift. Record review showed that the Treatment Administration Record (TAR) was marked as completed daily, indicating the dressing change was performed, even though the date on the dressing and the resident's statement suggested otherwise. The Director of Nursing confirmed the discrepancy between the TAR documentation and the actual date on the dressing, acknowledging that the TAR should only be marked as completed after the treatment is performed. This failure resulted in the resident not receiving care as ordered and documented.