Incomplete Documentation of Wound Care in Resident Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who was admitted with diagnoses including heart failure, anemia, and type 2 diabetes, and who was at risk for pressure ulcers. Record review showed that wound care documentation was missing for several dates, as indicated by gaps in the Treatment Administration Record (TAR). Despite the resident and staff stating that wound care was consistently provided, there was no documentation to confirm that wound care was completed on the specified dates. Interviews with the Director of Nursing (DON), an LVN, and an RN revealed that the missing documentation was attributed to staff not marking the wound care as completed in the electronic tracking system, often due to being busy or distracted. The facility's policy requires complete and accurate documentation for each resident, but this was not followed, resulting in incomplete records for the resident's wound care.