Inaccurate Documentation of Compression Wrap Application
Penalty
Summary
The facility failed to ensure accurate and truthful documentation regarding the application of compression wraps for a resident with a physician's order for daily application and removal of the wraps to both legs for lymphedema. Review of the Treatment Administration Record (TAR) showed that nursing staff documented the application of compression wraps at 8:00 AM. However, during an interview and observation at 10:00 AM, the resident stated she did not have compression wraps on, and it was confirmed by direct observation that no wraps were present on either leg. Further investigation revealed that the nurse whose initials appeared on the TAR as having applied the wraps at 8:00 AM stated she did not actually perform the task and was unaware of how her initials were recorded for that time. The nurse also indicated she did not know the frequency or timing for the application or removal of the wraps. Both the DON and the Administrator confirmed that the expectation is for staff to accurately document only the tasks they have personally completed, and that initials on the TAR should reflect the individual who performed the task.