Failure to Document Pressure Ulcer Wound Care Treatments
Penalty
Summary
The facility failed to ensure that a resident with a Stage 4 pressure ulcer received necessary wound care treatment and services consistent with professional standards of practice. According to the facility's policy, wound treatments are to be provided in accordance with physician orders and documented on the Treatment Administration Record (TAR). Medical record review showed that the resident, who had diagnoses including osteomyelitis and paraplegia, had a physician's order for daily wound care involving multiple topical medications and dressings. However, the TAR revealed multiple dates across three months where wound care treatments were not documented as completed or refused. During an interview, the Director of Nursing confirmed that if a resident refuses wound care, this should be documented, and that the TAR should not have blank days for wound care treatments. The lack of documentation on the specified dates indicates that the facility did not consistently record whether wound care was provided or refused, as required by both facility policy and professional standards.