Failure to Document Wound Care on Treatment Administration Record
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards for one resident. Specifically, wound care dressing changes for a male resident with a stage 3 pressure ulcer to the coccyx-buttock area were not documented on the Treatment Administration Record (TAR) for three consecutive days. The resident's care plan required daily wound care as ordered by the physician, and the facility's policy stated that treatment administration should be noted in the resident chart. However, review of the TAR showed missing nurse initials for the specified dates, indicating a lack of documentation. Interviews revealed that the RN responsible for the resident's care on those dates did provide the wound care as ordered but failed to document it due to being very busy. The RN acknowledged the omission and recognized it as a mistake. The Director of Nursing confirmed that documentation should have occurred after providing care, as it is a basic nursing responsibility and essential for communication. The lack of documentation was directly attributed to the RN's failure to record the wound care after administration.