Failure to Accurately Document and Perform Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to accurately document and perform wound treatment for a resident with multiple complex medical conditions, including surgical aftercare, diabetes, infection, and an abdominal surgical wound. The resident was admitted with an order for specific wound care, including cleansing with normal saline, application of Adaptic on biological mesh, packing with acetic acid-soaked gauze, and covering with a dry dressing, to be performed every shift. Documentation showed that the wound care was charted as completed on both the day and night shifts of a specific date. However, during an interview, the LPN assigned to the night shift admitted that she did not perform the wound care due to a busy shift and was unaware of a change in the wound care order. She also stated that she mistakenly charted the treatment as completed. The DON confirmed that the wound care was missed on the night shift, as reported by both the resident and the LPN, despite documentation indicating otherwise. The facility's policy requires that nursing documentation accurately reflect the care provided and the resident's progress. The inaccurate documentation and failure to perform the ordered wound care resulted in a deficiency, as the medical record did not provide an accurate representation of the resident's experience or care received.