Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for six out of eight residents, specifically regarding the documentation of wound care treatments as ordered in the electronic medical record. For multiple residents, staff did not mark the completion of wound care treatments on specific dates, despite physician orders requiring daily or scheduled wound care. The treatment administration records (TARs) for these residents contained blanks where documentation of wound care should have been recorded, indicating either the care was not provided or not documented. Residents affected had various medical conditions, including cirrhosis of the liver, atherosclerosis with gangrene, spinal stenosis, and cerebral infarction. For example, one resident with a right-hand skin tear did not have wound care documented on three separate days, while another with an above-knee amputation and groin wounds had missing documentation on four days. Other residents with surgical wounds, scalp lesions, and staples also had incomplete wound care documentation on multiple dates as required by their treatment orders. Interviews with staff revealed that nurses sometimes found it difficult to document every treatment due to workload, and that blanks in the TAR could mean either the care was not completed or simply not recorded. The Assistant Director of Nursing acknowledged that blanks in the records signified wound care was not documented and noted that some staff had been disciplined for not completing electronic medical record entries. The facility's own policy requires that all treatments and services provided to residents be documented in the medical record to facilitate communication among the care team.