Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, as required by professional standards. Specifically, the treatment administration records (TARs) for all three residents did not consistently document the completion of wound care treatments on multiple dates, despite physician orders and care plans indicating that daily wound care was necessary. The missing documentation was identified through observations, interviews, and record reviews during a complaint investigation. One resident, a male with a history of type 2 diabetes, foot ulcer, cirrhosis, peripheral vascular disease, and stage 4 pressure ulcers, was observed with bandaged wounds and reported receiving treatment for two wounds. His TARs for September and October did not reflect completion of wound care on several dates, even though daily treatment was ordered. Another resident, a female with severe cognitive impairment, unstageable pressure ulcer, morbid obesity, diabetes, and chronic respiratory failure, also had missing documentation for required daily wound care on specific dates. A third resident, a male with diabetes, MRSA infection, anemia, end-stage renal disease, and a below-knee amputation, had similar gaps in documentation for daily wound care to his left heel, right buttocks, and amputation site. Interviews with the wound care nurse, ADON, and DON confirmed that the TARs were not marked as completed on the identified dates. Staff indicated that the absence of documentation could be due to treatments being marked elsewhere, electronic medical record glitches, or the treatments not being performed or recorded. The only way to verify if the treatments were provided was to ask the nurse on duty, as no refusals or reasons for missed treatments were documented. The lack of documentation meant there was no reliable record of whether the prescribed wound care was actually administered.