Failure to Accurately Document and Perform Wound Care as Ordered
Penalty
Summary
The facility failed to follow its policy and procedure for charting and documentation in accordance with professional standards of practice for one resident. The deficiency occurred when licensed nurses did not change a resident's wound dressing every shift as ordered by the physician for two consecutive days. Despite this, the electronic medical record indicated that the wound treatment was completed during those days. The discrepancy was discovered through observation, interview, and record review, which revealed that the wound dressing was last changed and dated several days prior, contrary to the documentation in the Treatment Administration Record (TAR). The resident involved was admitted with a diagnosis of a cervical spinal cord injury and a stage 4 pressure ulcer on the coccyx. The resident was cognitively intact and reported that the wound dressing had not been changed as ordered, despite repeated requests to nursing staff. Observation confirmed that the wound dressing was not changed for two days, and the dressing was still dated from the last documented change. Interviews with nursing staff and supervisors confirmed that the facility's process required wound dressings to be changed as ordered, initialed, and dated, and that documentation should accurately reflect care provided. Further review of facility policy and professional standards emphasized the importance of accurate, complete, and objective documentation of all treatments and services performed. The facility's own staff acknowledged that the documentation in the TAR was false, as it did not match the actual care provided. The expectation was for nurses to notify supervisors if a treatment could not be completed, and to ensure all services were properly documented in the resident's medical record.