Failure to Document Wound Care Treatments in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, the treatment administration record (TAR) did not reflect documentation of wound care treatments on three separate dates, despite physician orders requiring daily wound care to the left plantar medial foot. The electronic medical record showed missing entries for these dates, and the Director of Nursing (DON) confirmed that a blank entry indicated the nurse had not documented whether the treatment was provided or refused. This lack of documentation meant that staff could not verify if the wound care was performed as ordered. The resident involved was a male with a history of type 2 diabetes with complications, post-surgical amputation, and anemia. He was at risk for pressure ulcers, had limited lower extremity mobility, and required significant assistance with daily activities. During observation, the resident was found with an above-the-knee amputation and reported ongoing wound issues. The facility's policy required all treatments and services to be documented in the medical record to ensure communication among the care team, but this was not followed in the cited instances.