Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented in accordance with accepted professional standards for one resident reviewed for skin condition. Specifically, the medical record for a resident with a history of diabetes, hyperlipidemia, depression, and a recent surgical amputation did not contain evidence that wound treatment was administered as ordered on multiple days. The resident's care plan required daily wound care, and physician orders detailed a specific wound treatment regimen. However, the Treatment Administration Record showed missing or incomplete documentation for several dates, and there was no corresponding information in the Nursing Progress Notes for those days. Interviews with nursing staff revealed that the assigned nurses could not recall why documentation was missing and were unable to confirm whether the wound treatments were completed or refused on the specified dates. The Assistant Director of Nursing stated that the treatments were provided but not documented due to newly hired nurses missing the documentation process. The Director of Nursing could not confirm any refusals of treatment on the days in question, and there was no evidence in the medical record to support that the treatments were either completed or refused.