Failure to Document Wound Care and Resident Refusals
Penalty
Summary
A deficiency was identified when the facility failed to ensure complete and accurate documentation of wound care for one resident. The resident, who had a history of cellulitis, right toe amputation, congestive heart failure, MRSA, and diabetes, was admitted with an order for daily and evening wound care and dressing changes to the right foot. Review of the Treatment Administration Record (TAR) revealed that documentation was missing for the day shift on 3/16/25 and the evening shift on 3/17/25, with no indication that the dressing changes were completed or refused. Interviews with nursing staff confirmed that the resident had refused the dressing changes on the dates in question. However, the assigned nurses did not document the refusals on the TAR or in a progress note, as required. One nurse acknowledged forgetting to document the refusal due to being busy, and it was noted that the resident often refused dressing changes. The lack of documentation was confirmed by the unit manager and discussed with facility leadership.