Failure to Document and Administer Wound Care per Physician Orders
Penalty
Summary
The facility failed to ensure that two residents received wound care treatment and documentation in accordance with physician orders, professional standards, and the residents' care plans. For one resident with a history of traumatic brain injury, type II diabetes, and venous insufficiency, the treatment administration record (TAR) showed that wound care for a post-surgical right calf wound was not documented as completed on eleven occasions across two months. The resident's care plan and physician orders specified daily wound care, but these were not consistently documented as performed. Another resident, with diagnoses including type II diabetes, chronic kidney disease, and hemiplegia following a stroke, had physician orders for daily wound care to both heels due to stage 4 pressure injuries. The TAR indicated that wound care for both heels was not documented as completed on four separate dates. Both residents were assessed as being at risk for pressure ulcers, and their care plans required wound care interventions as ordered by their physicians. Interviews with facility staff, including licensed nurses and administrative personnel, confirmed that treatments were expected to be documented when completed, and that a blank on the TAR indicated the treatment was not done. The facility's wound care policy outlined documentation requirements, but there was no specific policy for documentation practices. The Director of Nursing and other staff acknowledged the expectation for accurate and timely documentation of wound care, and the administrative team was responsible for monitoring this process.