Failure to Document Wound Treatments and Refusals
Penalty
Summary
The facility failed to accurately document completed wound treatments or treatment refusals for a resident with multiple pressure ulcers and significant medical needs. Review of the Treatment Administration Record (TAR) revealed that, for several wound care orders, numerous entries were left blank, indicating that staff did not record whether treatments were completed or refused. Specifically, for multiple wound care orders, between two and fourteen out of the total opportunities for documentation were left blank. The resident's care plan noted a history of resistance to care and frequent refusals of wound treatments, but the TAR did not consistently reflect whether treatments were administered or refused. Interviews with facility staff, including an LPN, the wound nurse, the DON, and a nurse practitioner, confirmed that staff are expected to document all treatments or refusals in the TAR, and that the electronic medical record system prompts for a reason if a treatment is not completed. However, staff were unable to explain the blank entries, with one LPN suggesting it could be due to forgetting to chart. The lack of documentation was not in accordance with facility policy, which requires clear and accurate recording of all medical provider orders and treatments.