Failure to Accurately Document Wound Care, Medication Administration, and Device Assessment
Penalty
Summary
The facility failed to maintain accurate and complete medical records for multiple residents, resulting in deficiencies related to documentation of wound care, medication administration, and assessment of medical devices. For one resident with a chronic unstageable sacral wound, nursing staff did not consistently document the administration of prescribed wound treatments on the Treatment Administration Record (TAR) or in the electronic medical record on several dates. Interviews with assigned nurses and the wound treatment nurse confirmed that wound care was performed but not properly documented, attributing the lapses to documentation errors. Additionally, the assessment of an implanted device for the same resident was inaccurately documented, with an agency nurse initially unaware of the device's presence but still signing off on the TAR as if the site had been monitored for infection. Another resident with an order for hydralazine, an antihypertensive medication, was affected by inaccurate documentation on the Medication Administration Record (MAR). The order specified that the medication should be held if the systolic blood pressure was less than 125 mmHg. However, the MAR showed the medication as administered on several occasions when, according to interviews with nursing staff and a medication aide, it had actually been held in accordance with the order. The staff acknowledged that these were documentation errors, as they had not accurately recorded when the medication was withheld. A third resident, who required hemodialysis and had an A/V dialysis shunt, experienced similar documentation issues. Physician orders required the removal of a pressure dressing over the shunt site 4-6 hours after returning from dialysis and for the site to be checked for bleeding, infection, bruit, and thrill. Nursing staff recorded on the MAR that they had removed the dressing and checked the site on specific dates, but interviews revealed that the dressing was not actually removed as ordered, and the documentation was inaccurate. The Assistant Director of Nursing also identified an error in the way the order was entered, which contributed to the confusion and subsequent documentation inaccuracies.