Inaccurate and Incomplete Documentation of Wound Care
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records regarding wound dressing changes for three residents with wounds requiring dressings. For one resident with multiple pressure sores and venous wounds, the Treatment Administration Record (TAR) was signed by a nurse for dressing changes that he did not perform, as confirmed during an interview. The nurse stated he had not changed the dressings as documented and believed another nurse had performed the care. The administrator confirmed that nurses should not sign for treatments they did not complete. Another resident, who had undergone surgery for skin cancer and required daily wound care, had a blank entry on the TAR for a day when the dressing change was performed but not documented. The nurse responsible admitted to completing the dressing change but failing to record it. For a third resident with a stage 3 pressure wound, the TAR indicated that two nurses had completed dressing changes on a specific date, but both nurses confirmed in interviews that they had not performed the care, and the treatment nurse stated the dressing had not been changed since two days prior. The administrator acknowledged that staff should not sign for care not provided.