Failure to Complete and Document Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to provide necessary wound care treatment and services consistent with professional standards of practice for a male resident with multiple diagnoses, including type II diabetes, chronic kidney disease, and hemiplegia following a stroke. The resident was identified as being at risk for pressure ulcers and had existing deep tissue injuries (DTIs) to both heels. Physician orders were in place for daily wound care treatments to both heels, including cleansing, application of a collagen sheet, and appropriate dressings. However, review of the Treatment Administration Records (TARs) for May and June 2025 showed that wound care treatments for both heels were not documented as completed on four separate occasions. Interviews with nursing staff and administration confirmed that treatments are expected to be completed and documented as ordered, and that a blank on the TAR indicates the treatment was not done. The facility's wound care policy also requires documentation of the type of care given, date and time, and the name and title of the person performing the care. The Director of Nursing, who was new to the facility, stated she expected daily treatments to be completed and documented as ordered. The lack of documentation and missed treatments could result in residents not receiving appropriate care and treatment.