Incomplete Documentation of Wound Care in Medical Records
Penalty
Summary
The facility failed to ensure that medical records for a resident were maintained in accordance with accepted professional standards and practices. Specifically, the Treatment Administration Record (TAR) for a resident with multiple chronic conditions, including chronic heart failure, diabetes with neuropathy, lymphedema, and peripheral vascular disease, contained blanks on four out of fourteen designated wound care treatment days. These blanks indicated that the completion or refusal of prescribed wound care was not accurately documented for the specified dates. The resident was prescribed wound care to be performed twice weekly and as needed, with clear orders for cleansing, application of medication, and dressing changes. Observations and interviews revealed that the resident's dressings were not always changed as scheduled, and the resident herself reported that wound care was not consistently provided on the assigned days. The nurse responsible for treatments acknowledged that documentation was sometimes missed, either because she was not present or because she forgot to document after providing care. In cases where the resident refused care, this was also not consistently recorded on the TAR as required. The Director of Nursing confirmed the presence of documentation gaps and stated that refusals or completed treatments should have been properly recorded on the TAR. Facility policy required detailed documentation of wound care, including the type of care given, date and time, assessment data, and any refusals with reasons. The lack of accurate and complete documentation on the TAR made it difficult to determine whether wound care was provided or refused on the specified dates.