Incomplete Documentation of Wound Care in Clinical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for two residents who were receiving wound care. For one resident, the Treatment Administration Record (TAR) did not show evidence that wound vac dressings were changed as ordered on specific dates, despite physician orders specifying the frequency and timing of these changes. For another resident, the TAR lacked documentation that wound care for both the right heel and left foot was completed on several dates, even though there were clear orders for daily wound care and dressing changes. These deficiencies were identified through review of medical records and confirmed in discussion with the Director of Nursing and the Director of Clinical Operations.