Failure to Document Wound Care Assessments and Treatments
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one resident with a skin impairment. Record review showed that the resident had an open area on the coccyx, and the medical provider was notified. The wound care nurse (WCN) was assigned to treat the area, and the plan was to follow up with daily assessments and treatment. However, there was no documentation by the WCN in the resident's medical record regarding her assessments or treatments of the wound. Interviews with staff confirmed the lack of documentation. The LPN stated that the WCN was treating the area, and the WCN herself acknowledged that she had not documented her assessments or treatments, despite assessing the wound and planning interventions. The Director of Nursing (DON) also confirmed that the WCN should have documented these observations, assessments, and treatments in the resident's medical record, but this was not done.