Failure to Accurately Document Wound Care Treatments in TAR
Penalty
Summary
The facility failed to maintain accurate Treatment Administration Records (TAR) for a resident with diabetes mellitus and bilateral below knee amputations. Physician orders were in place for daily wound care to both amputation sites, including cleansing, application of petrolatum dressing, and securing with gauze and ACE bandage. Record review revealed multiple dates in June and July where there was no documentation on the TAR to indicate that the ordered treatments were completed. Specifically, there were missing entries for several days, despite physician orders specifying daily and as-needed wound care. Interviews with nursing staff who worked on the dates in question revealed that while they assured the treatments were completed, they failed to document them in the TAR. Reasons provided included being busy, unfamiliarity with the electronic medical record system, and simply forgetting to sign off after completing the treatments. The Director of Nursing confirmed that nurses were educated to sign off treatments as they were completed and that this was the facility's expectation.