Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented in accordance with accepted professional standards and practices for one resident. Specifically, a resident with diagnoses including non-Alzheimer's dementia, congestive heart failure, and peripheral arterial disease had a physician's order for daily wound care to the right medial bunion. The treatment administration record and nursing progress notes showed multiple dates over a two-month period where wound care was not documented as completed, and there was no documentation explaining the omissions. The facility's policy required that all events pertaining to a resident's stay, including treatments, be documented by licensed professionals. Interviews with nursing staff and facility leadership revealed uncertainty about whether the wound care was provided on the undocumented dates. Staff members could not recall the resident or the specific treatments, and some suggested that either the wound care team performed the treatment or the resident was not present or refused care. However, there was no documentation to support these explanations. The Assistant Director of Nursing confirmed that no additional documentation could be found to clarify the missing entries, and stated that unsigned treatment administration records indicate that care was not rendered.