Failure to Accurately Document New Pressure Injury and Wound Treatments
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident when a new pressure injury was identified and wound treatments were not properly documented. Although a physician's order was written for wound care after a new skin issue was reported, there was no documentation in the medical record regarding the change in the resident's skin integrity on the date the issue was discovered. Additionally, the Treatment Administration Record (TAR) showed missing documentation for wound treatments on two days and indicated that treatments were not administered on four other days, despite the wound nurse being scheduled to work on those dates. Interviews with staff revealed that the wound nurse assessed the resident and obtained treatment orders but did not document the new pressure injury in the medical record. The wound nurse acknowledged that treatments were likely completed but may not have been signed off in the TAR, and that second shift nurses sometimes marked treatments as not administered to clear them from their screens. Other nursing staff confirmed that they did not complete the treatments when signing them as not administered. Both the Nurse Practitioner and Medical Director stated that new skin issues and treatments should be accurately documented, and the Director of Nursing and Administrator expected the TAR and medical records to reflect care provided.