Failure to Accurately Document Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, specifically by not documenting the completion of wound care treatments as ordered. The resident, a female with a below-the-knee amputation and multiple comorbidities including osteonecrosis, diabetes, atrial fibrillation, cirrhosis, and chronic kidney disease, was readmitted to the facility and required surgical wound care four times weekly. Observations and interviews revealed that the treatment administration record did not reflect completion of wound care on three specific dates, despite physician orders and the resident's care plan requiring these treatments. During interviews, staff indicated that wound care was typically performed by a designated wound care nurse, but on at least one occasion, another nurse provided the care and failed to document it. The Director of Nursing confirmed that the treatment administration record was not marked as completed on the specified dates and acknowledged that without this documentation, it could not be confirmed whether the care was provided. The resident herself reported that wound care was not always performed daily as expected.