Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure complete documentation of wound care treatments for one resident with multiple pressure ulcers. According to the facility's own wound care policy, specific information must be recorded in the medical record after each wound treatment, including the type of care given, date and time, resident positioning, the name and title of the caregiver, assessment data, resident tolerance, and any problems or refusals. However, review of the clinical record for a resident diagnosed with hemiplegia, hemiparesis, and stage 4 sacral pressure ulcer revealed missing documentation for wound treatments on several dates for multiple wound sites, including the right buttock, right heel, sacrum, left ischial, and lateral ankle. The absence of required documentation was noted on multiple occasions, with no records of wound care being completed for the specified areas on the identified dates. The facility's failure to document these treatments is not in accordance with accepted professional standards and the facility's own policy, as required by regulation. The findings were based on a review of clinical records and facility-provided documentation.