Failure to Document Wound Treatments for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to document wound treatments as ordered for a resident with a Stage 3 pressure ulcer. Review of the Electronic Treatment Administration Record (ETAR) for this resident revealed multiple instances across April, May, and June where wound care treatments were not documented as administered, despite active physician orders. Specifically, there were fifteen days with missing documentation for wound care treatments, including cleaning, application of medications, and dressing changes. Interviews with nursing staff indicated that while treatments may have been performed, documentation was not consistently completed in the ETAR. The Director of Nursing confirmed the expectation that all treatments should be documented and acknowledged the missing entries. The resident involved had a history of chronic kidney disease and dementia and was rarely or never understood, according to the Minimum Data Set. The wound was observed to have pink granulation tissue at the time of survey, and staff interviews indicated that wound management services were provided weekly. However, both the treatment nurse and other nursing staff admitted to occasional lapses in documentation, particularly during busy periods or on weekends, leading to incomplete records of wound care provided.