Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete, accurate, and up-to-date medical records for a resident who was receiving wound care for a non-pressure related skin injury. The resident had a history of a non-pressure chronic ulcer of the buttock, recent major surgery for repair of a deep ulcer, and required a wound VAC with specific dressing change orders. Documentation was missing for several wound care treatments, including a wound VAC dressing change performed by a wound care provider, a wet-to-dry dressing change performed by an LPN after the wound VAC device failed, and a subsequent wound VAC dressing change performed by an RN prior to the resident's transfer to the hospital. Additionally, there was no physician order documented for the wet-to-dry dressing that was applied when the wound VAC failed. Interviews with nursing staff and the nurse manager confirmed that these treatments were not documented in the resident's medical record or treatment administration record (TAR), and that the medical record was therefore incomplete and inaccurate. The nurse manager and interim DON both acknowledged the importance of accurate documentation for continuity of care and confirmed that the expected documentation was missing. The facility's policy regarding the contents of medical records was requested but not provided.