Failure to Document Physician-Ordered Treatments for Multiple Residents
Penalty
Summary
Facility staff failed to document physician-ordered treatments for four residents, as evidenced by interviews and record reviews. The facility's Wound Treatment Management policy requires that all treatments be documented on the Treatment Administration Record (TAR) or in the electronic health record. However, multiple instances were identified where staff did not document the administration of prescribed treatments, including topical medications, wound cleansers, and dressings, on specific dates for each resident. One resident with a gluteal cleft wound did not have documentation for hydrocortisone cream and Dakin's solution treatments on several occasions. Another resident with a right gluteus wound and osteoarthritis lacked documentation for Voltaren gel applications as ordered. A third resident with lymphedema, cellulitis, and localized edema was missing documentation for wound care procedures, ace wrap applications, and topical steroid cream on multiple dates. The fourth resident, who had a history of stroke, edema, and wounds, also had missing documentation for ace wrap applications and wound care treatments. Interviews with the administrator and DON confirmed that all treatments are expected to be documented in the electronic health record, and if a treatment is not given, the reason should be recorded. Both were unable to explain why staff failed to document the treatments, and one resident reported not receiving leg treatments even after requesting them.