Incomplete Documentation of Wound Care Treatments
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain complete and accurate clinical records regarding wound treatments for one resident with pressure ulcers. Specifically, a resident with diagnoses including diabetes and fractures was admitted with surgical wounds and later developed a pressure injury to the left heel. The care plan required following facility protocols and physician orders for wound care. However, review of the Treatment Administration Record (TAR) for the relevant month showed that wound care was not signed out on two specific dates. During interviews, the wound nurse acknowledged performing the treatments but admitted to forgetting to document them, citing increased workload due to being the only wound nurse available that week.