Failure to Document Wound Care Administration in Resident Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents who required wound care, as evidenced by missing documentation of wound care administration on multiple occasions. For one resident with a history of dementia, gangrene, chronic foot ulcers, diabetes, malnutrition, and rheumatoid arthritis, there was no documentation of wound care provided on four specific dates in June, despite physician orders and a care plan indicating the need for daily wound management. The resident's treatment administration record (TAR/WAR) and nursing progress notes did not reflect any reason for the missed documentation or whether the care was provided. Another resident, with diagnoses including diabetes, aphasia, stroke, anoxic brain damage, and dysphagia, also had missing documentation for wound care on three dates in June. This resident required substantial assistance with activities of daily living and had a physician order for sacral wound care. The TAR/WAR did not show that wound care was signed off on the specified dates, and there was no additional documentation in the nursing notes to explain the omissions. Observation confirmed the presence of a wound dressing, but the required documentation was incomplete. A third resident, with a history of cellulitis, chronic leg ulcers, gout, and lymphedema, had no documentation of wound care on four dates in May, despite multiple physician orders for wound management of several leg and toe ulcers. The care plan did not address all of the resident's wounds, and the TAR/WAR and nursing progress notes lacked entries for the missed dates. Interviews with nursing staff revealed that wound care documentation was expected to be completed in the electronic charting system, and missing entries would remain flagged until resolved. However, the system showed unresolved entries, and staff acknowledged that treatments may have been performed but not documented.