Incomplete and Inaccurate Documentation of Wound and Nephrostomy Care
Penalty
Summary
The facility failed to ensure complete and accurate documentation of wound care and dressing changes for two residents. For one resident with a history of schizoaffective disorder, vascular dementia, pain, and functional quadriplegia, there were inconsistencies and omissions in the Treatment Administration Record (TAR) regarding dressing changes to a sacral pressure wound. Specifically, no treatment was recorded on two scheduled dates, and a nurse admitted to signing off on a dressing change that was not performed. During observation, the dressing on the resident's wound was found to be dated from a previous week, indicating that scheduled changes may not have occurred as documented. For another resident with diagnoses including hydronephrosis, chronic kidney disease, and type 2 diabetes, the TAR reflected that dressing changes to nephrostomy sites were signed off as completed on two dates. However, both resident interviews and direct observations revealed that no dressings were present on the nephrostomy sites during those times, and the resident reported that only lotion was applied to her back. The nurse responsible for the documentation confirmed that she had not performed the dressing changes as recorded and had intended to do them later, but had already documented them as completed. Facility policy requires accurate documentation of wound care and nephrostomy tube care, including the date, time, and person performing the procedure, as well as the resident's response. Interviews with the Director of Nursing and the administrator confirmed that their expectation is for care to be provided and documented as ordered, and that incomplete or inaccurate documentation could result in residents not receiving necessary treatments.