Failure to Document Wound Care and Refusals in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who was reviewed for clinical records. Specifically, the wound treatment administration record for a male resident with severe cognitive impairment and a history of wound care refusal did not contain any documentation of wound care from 10/01/25 to 10/06/25, despite orders for daily wound care. Interviews with nursing staff revealed that the resident frequently refused wound care, and staff had to involve the resident's family to encourage compliance. However, these refusals and the attempts to provide care were not documented in the treatment administration record as required by facility policy. The facility's own policies require that all treatments be documented on the Treatment Administration Record and that complete and accurate documentation be maintained for each resident. Both the administrator and the DON acknowledged during interviews that refusals of wound treatment should have been documented to ensure the accuracy of the resident's records. The lack of documentation for the specified period was confirmed through record review and staff interviews.