Failure to Complete and Document Pressure Injury Treatments
Penalty
Summary
The facility failed to ensure that pressure injury treatments were completed and properly documented for two out of three residents reviewed for pressure injuries. For one resident with a stage 4 pressure ulcer on the left lower back and multiple comorbidities including diabetes, COPD, and peripheral vascular disease, the Treatment Administration Record (TAR) showed that prescribed wound care treatments were not signed off as completed on several weekend dates. The wound care nurse confirmed that treatments should be documented after completion and that if not documented, it is considered not done. The resident's care plan required wound management per treatment orders, and facility policy mandated that staff initial the TAR after each administration. Similarly, another resident with a stage 3 pressure ulcer on the right ankle, along with diagnoses such as right-sided hemiplegia, obesity, and traumatic brain injury, had wound care treatments that were not signed off as completed on multiple weekend dates. The wound care nurse again confirmed the lack of documentation and reiterated the importance of following treatment orders. The care plan for this resident also required wound care per treatment orders, and the facility's policy specified that physician-ordered treatments must be documented on the TAR after each administration.