Failure to Document Wound Care for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper documentation of wound care for two of three sampled residents with pressure ulcers. For one resident with severe cognitive impairment and multiple pressure ulcers, physician orders specified wound care regimens for different wounds, including cleansing and dressing changes on specific days and shifts. However, review of the treatment administration records revealed missing documentation for several scheduled wound care dates and shifts. Interviews with wound care nurses confirmed that while the wound care was reportedly performed, it was not consistently documented in the treatment administration records as required. Another resident, also with severe cognitive impairment and a stage 3 pressure ulcer, had physician orders for wound care on designated days. The treatment administration record for this resident similarly lacked documentation for several scheduled wound care dates. Nursing staff acknowledged that the wound care was completed but not recorded. The Director of Nursing stated that daily audits and weekly monitoring of treatment records were in place, but the documentation failures persisted during the review period.