Failure to Document Wound VAC Orders and Treatments
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident who was admitted with a stage 4 pressure ulcer and required a wound VAC. Upon admission, the resident's medical record did not contain complete documentation of wound assessments, wound VAC orders, or wound care treatments. Although the facility's policy required a physical skin evaluation and documentation upon admission, as well as ongoing monitoring and care planning, these steps were not fully carried out for this resident. Staff interviews revealed that the wound VAC was applied after admission and experienced issues with maintaining suction, leading to multiple dressing changes and the need to order a replacement device. Despite these interventions, there was no documentation of wound VAC orders specifying pressure settings, frequency of dressing changes, or monitoring instructions in the resident's medical record. Additionally, wound care and dressing changes performed by staff were not consistently documented, and the required wound assessment upon admission was not completed or recorded. Multiple staff members, including LPNs, the ADON, and the DON, acknowledged that documentation was lacking and that proper orders and assessments should have been present in the resident's chart. The absence of these records meant that the facility did not comply with its own policies or accepted professional standards for maintaining accurate and complete medical records for residents with wounds requiring specialized care.