Failure to Accurately Document and Transcribe Wound Care Orders
Penalty
Summary
The facility failed to properly transcribe and document treatment orders and wound care for multiple residents, resulting in incomplete and inaccurate medical records. For one resident with significant medical needs, including bilateral amputations and end-stage renal disease, the facility did not transcribe new wound care orders following a hospital readmission. The Treatment Administration Record (TAR) continued to reflect outdated orders, and there was no documentation explaining why treatments were held or not administered. Additionally, there was no record of the new wound vacuum therapy or barrier ointment orders from the hospital, and the progress notes lacked details about changes in treatment or the resident's transitions in and out of the facility. For two other residents with pressure ulcers and other wounds, the TAR contained multiple blank entries and notations indicating treatments were not administered, without any corresponding documentation in the progress notes to explain the omissions or refusals. The facility's policies required that all treatments and refusals be documented, and that physician orders be accurately transcribed and implemented. However, the records showed repeated failures to document whether treatments were completed, refused, or why they were not given. Staff interviews confirmed that blanks on the TAR meant treatments were either not done or not signed off, and that there was confusion about documentation responsibilities when residents left or returned to the facility. The deficiencies were further compounded by inconsistent documentation practices among nursing staff and a lack of clarity regarding who was responsible for entering and updating treatment orders. The facility's own policies emphasized the need for complete, accurate, and timely documentation of all clinical care, including wound treatments and resident refusals. Despite these policies, the survey found that essential information was missing from the medical records, and there was no evidence that physicians were notified when treatments were not administered as ordered.