Failure to Document and Administer Physician-Ordered Wound Treatments
Penalty
Summary
Facility staff failed to maintain professional standards of care by not documenting the administration of wound treatments as directed by physicians for two residents. For one resident, who was cognitively intact and had venous and arterial ulcers, physician orders required daily wound care on both lower legs. However, the Treatment Administration Record (TAR) lacked documentation of treatment or refusal on multiple specified dates. The Director of Nursing (DON) confirmed that refusals should be documented and that nurses are expected to record all treatments or refusals on the TAR. For another resident, also cognitively intact and receiving surgical wound care, physician orders required pin-site care every shift. The TAR did not contain documentation of wound treatment on several dates across two months. The resident reported that staff were not performing treatments every shift as ordered. The DON was unaware of any refusals and expected treatments to be administered as ordered. Interviews with staff and the administrator confirmed that missing documentation on the TAR likely indicated treatments were not completed, and that the DON was responsible for auditing and addressing missing documentation.