Failure to Complete and Document Physician-Ordered Skin Treatments
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
Staff failed to complete and document physician-ordered skin treatments for a resident with chronic kidney disease and acute on chronic diastolic heart failure, who was admitted with orders to wrap both legs with Kerlix and compression wraps every shift due to swelling, mass, and lumps in the lower limbs. Medical record review showed that the Treatment Administration Record (TAR) lacked documentation of treatment completion on several specified days and shifts. During an interview, the DON confirmed that the treatments were not signed off as completed on those dates and could not verify whether the treatments had actually been performed.