Failure to Provide and Document Ordered Wound Care
Penalty
Summary
The facility failed to provide and document ordered wound care for two residents with multiple wounds, as evidenced by missing documentation on the Treatment Administration Records (TAR) and lack of progress notes for several dates when wound care was scheduled. One resident, with diagnoses including dementia, diabetes type 2, heart failure, and an antibiotic-resistant infection, had orders for daily wound treatments to both legs. The TAR and progress notes showed that wound care was not documented as completed on multiple occasions, and there was no explanation for the missing treatments. The Director of Nursing confirmed that wound care should be documented when performed and that documentation is necessary to verify completion. Another resident with skin tears to the left foot and knee had orders for wound care three times a week. The TAR indicated that wound care was not documented as completed on specific dates for both wounds. The resident reported that staff were sometimes too busy to perform wound treatments. Additionally, when requested, the facility was unable to provide a policy for wound care treatment.