Incomplete Documentation of Wound Care in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted with multiple complex diagnoses, including Guillain-Barre disease, respiratory failure, and a tracheostomy. Specifically, the resident was prescribed daily wound care for a sacral pressure injury, but the November treatment administration record (TAR) lacked documentation of wound care on several specified dates. The care plan and physician's orders indicated the need for daily and PRN wound care, yet the TAR showed blanks for the prescribed treatment on multiple days. Interviews with facility staff confirmed the expectation that all care should be documented as soon as it is provided, and the Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the missing documentation in the resident's record. The resident's representative reported that the facility neglected general care and wound care, stating that the resident did not consistently receive the prescribed wound care and that the representative had to provide dressings personally. The DON stated that the wound was improving according to the wound care physician's documentation but was unaware of the missing entries in the TAR. The facility's policy requires accurate maintenance of medical records, but the lack of documentation for wound care on the specified dates resulted in incomplete and unorganized records for the resident.