Failure to Document Completion of Wound Treatments
Penalty
Summary
The facility failed to document the completion of wound treatments provided to a resident with pressure ulcers. Physician's orders were in place for the resident to receive specific wound care treatments for a posterior scrotal skin tear and a right groin abrasion, including cleansing, application of collagen particles, zinc oxide paste, bordered gauze, and calcium alginate with silver. A review of the resident's medical record and Treatment Administration Record (TAR) did not show any documentation that these treatments were completed on the specified date. During interviews, the Wound Care Nurse confirmed that she had performed the ordered treatments but could not explain why she had not documented them in the resident's medical record or TAR. Both the DON and the Administrator acknowledged that the medical record should accurately reflect the care provided, and that the wound treatments should have been documented as completed.