Failure to Accurately Document Wound Care in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident reviewed for medical records. Specifically, there were multiple instances where wound care dressing changes were not documented on the Treatment Administration Record (TAR) for a resident with significant medical conditions, including sepsis, metastatic cancer, heart failure, severe malnutrition, and a Stage 2 pressure ulcer. The missing documentation occurred on several specific dates, despite active orders for wound care and interventions outlined in the resident's care plan. Record reviews showed that the resident required regular application of zinc-based cream to the buttock area for skin integrity issues and had a care plan addressing risks related to incontinence and impaired mobility. However, the TAR lacked documentation for wound care on multiple shifts, and skin and wound evaluation forms were incomplete, with sections for practitioner and interdisciplinary notifications left blank. Interviews with nursing staff, including the Wound Care Nurse, LVNs, and RN, confirmed that missing documentation on the TAR typically meant the treatment was not performed, and staff could not account for the omissions. Facility policy required that all assessments, observations, and services provided be documented accurately and timely in the resident's medical record. Staff interviews further revealed that when the Wound Care Nurse was not present, floor nurses were responsible for wound care, but documentation lapses still occurred. The Director of Nursing acknowledged that missing documentation would appear as if care was not provided, and that the facility's process included reviewing records for such lapses, yet the deficiency persisted for this resident.