Deficient Documentation of Wound Care and Insulin Administration
Penalty
Summary
The facility failed to accurately document wound descriptions upon admission and did not ensure medication administration was documented according to physician orders for two residents. For one resident with paraplegia and type 2 diabetes, the medical record review revealed inconsistencies in wound measurement documentation. The wound was measured in centimeters, but the recorded size did not match the measurements from an outside wound center, which showed significant changes in wound size before and after the resident's stay. Interviews with staff indicated uncertainty about proper wound staging and measurement protocols, despite facility policy requiring measurements in centimeters. For another resident with type 2 diabetes and moderate cognitive deficit, the facility did not document insulin administration according to physician orders. The medication administration record (MAR) showed multiple instances where insulin doses were recorded as given at times significantly different from the prescribed schedule. Staff interviews revealed that nurses sometimes delayed documentation, making it appear as though medications were administered late, and that time management challenges contributed to the issue, especially when nurses had to cover for medication aides who could not administer insulin. Facility policies required timely and accurate documentation of both wound care and medication administration, including adherence to the five rights of medication administration and real-time charting. However, the observed practices did not align with these policies, as evidenced by the discrepancies in wound documentation and the inconsistent timing of insulin administration entries in the MAR.