Inaccurate Documentation and Missed Wound Care for Resident with Venous Ulcers
Penalty
Summary
The facility failed to accurately document and perform wound care for a resident with multiple medical conditions, including atrial fibrillation, type II diabetes, chronic venous hypertension with ulceration, and pulmonary hypertension. Physician orders specified daily wound care to the resident's left lower extremity, including cleansing, application of a silver collagen sheet, hydrogel dressing, and securing with kerlix and tape, with documentation required on the Treatment Administration Record (TAR). However, during an interview and observation, the resident reported that her wound dressing had not been changed recently, and the dressing was found to be dated several days prior, despite TAR entries indicating daily wound care had been completed. Further review and interviews with the DON and an LPN confirmed discrepancies between the documented wound care and the actual care provided. The DON acknowledged that the TAR inaccurately reflected wound care as completed on days when it was not performed, and the LPN could not explain the inconsistencies between her initials on the TAR and the actual dates wound care was provided. This inaccurate documentation and failure to provide wound care as ordered resulted in a deficiency related to maintaining accurate medical records and safeguarding resident-identifiable information.