Failure to Maintain Complete and Accurate Clinical Records for Wound Care and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for multiple residents regarding wound care and medication administration. For one resident with severe cognitive impairment and multiple ulcers, treatment sheets did not show documentation of daily dressing changes on several specified dates, despite physician orders requiring these treatments. The Director of Nursing (DON) confirmed that there was no documentation for the dressing changes on the missing dates and acknowledged that undocumented treatments are considered not done. The resident was unsure about the frequency or progression of their wound care, and the DON was unable to locate any records for the specified dates. Another resident, who was cognitively intact and had an ostomy and pressure ulcers, had physician orders for wound care to multiple sites. The treatment administration record lacked documentation for wound care on a specific date, and staff later admitted that the wound care was performed but not documented. Additionally, a third resident with diabetes and a high cognitive score had missing documentation for insulin administration on three occasions, even though the resident stated they received their insulin as ordered. The DON confirmed the absence of documentation for these medication administrations.