Incomplete Documentation of Wound Care for Hospice Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with a stage 4 pressure ulcer who was on hospice care and had severe cognitive impairment. Specifically, the wound care documentation for this resident was incomplete for several dates in April and May, as wound care was not recorded as completed on multiple occasions. The resident's care plan required adherence to facility protocols for wound prevention and treatment, and physician orders specified daily wound care procedures. However, the wound care report lacked entries for several days, and staff interviews confirmed that documentation was either omitted or not possible to complete due to limitations in the electronic health record system. The Wound Care Nurse acknowledged that the absence of documentation would indicate that wound care was not performed, and another nurse stated that blank entries likely meant the Weekend Supervisor performed the care but failed to document it. Attempts to contact the Weekend Supervisor were unsuccessful. The DON confirmed that the expectation was for charge nurses to provide and document wound care on weekends, and that blank wound care reports could indicate care was not given. Facility policy required all treatments to be documented in the treatment administration record or electronic health record, which was not consistently done in this case.