Failure to Document Wound Care Provided to Resident
Penalty
Summary
A deficiency was identified when the facility failed to maintain accurate and complete medical records for a resident with quadriplegia, neurogenic bowel, and neuromuscular bladder dysfunction. The resident, who was cognitively intact, filed a grievance indicating that a nurse had changed their wound dressing following a bowel movement. However, a review of the Treatment Administration Record (TAR) and Progress Notes for the relevant date showed no documentation that the wound vacuum dressing was changed or that skin prep was applied, as ordered. The facility's policy required all services provided to be documented in the resident's medical record. Interviews with the resident, an LPN shift supervisor, and the Director of Nursing confirmed that the wound care was provided, but the LPN admitted to forgetting to document the treatment due to a shift change. The DON also acknowledged that documentation should have been completed to reflect the care provided. The lack of documentation resulted in an incomplete medical record, contrary to facility policy and accepted professional standards.