Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for one resident reviewed for clinical records. Specifically, wound care treatments for a resident with moisture associated skin damage (MASD) to the sacral area were not properly documented on the Wound Administration Record (WAR) for three scheduled treatments out of thirty-nine reviewed. The treatment order required cleansing the sacral area and applying Triad cream every day and evening shift, but the WAR showed blanks for three specific shifts, indicating missing documentation. Interviews with nursing staff revealed that the wound care nurse was not present on weekends, and direct care nurses were expected to provide and document wound care in her absence. One LPN recalled providing the treatment but admitted she did not document it, while another LPN, new to the facility, stated she may not have noticed the order in the electronic record and therefore did not mark it as completed. The Director of Nursing confirmed that a blank in the administration record typically indicates a missed administration or lack of documentation, which impacts the ability to monitor whether orders are being followed. The resident involved was cognitively intact, dependent for all self-care and mobility, and at risk for pressure ulcers, with a history of MASD. The resident could not recall if wound care was provided on the dates in question. Facility policy required that the person administering a treatment document it at the time of administration, but this was not consistently followed, resulting in incomplete clinical records for the resident.