Failure to Accurately Document Wound Care Treatments
Penalty
Summary
The facility failed to maintain accurate documentation of wound care treatments for one of two sampled residents, as required by facility policy and professional standards. Specifically, the Treatment Administration Record (TAR) for a resident with severe cognitive impairment and multiple wounds did not reflect wound care treatments on two separate dates, despite physician orders for daily dressing changes to the left great toe and left fifth metatarsal. The treatments included cleansing with normal saline, application of Betadine, Medi Honey, collagen alginate, abdominal pad, and gauze bandage roll. During interviews, the treatment nurse acknowledged providing the wound care but admitted to forgetting to document the treatments in the TAR. The facility's policy required that all services provided to residents be documented in the medical record with objective, complete, and accurate information, including the date, time, and signature of the individual providing care. Both the DON and Administrator confirmed that wound care treatments should be accurately documented to confirm care was provided as ordered. The lack of documentation resulted in an inaccurate representation of the care provided to the resident and had the potential to cause miscommunication among staff.