Failure to Accurately Document Wound Care on Treatment Administration Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical records for a resident receiving multiple wound care treatments. Physician orders for this resident included specific wound care to the right buttock starting 12/17/2025, to the left buttock starting 12/29/2025, and to the right lateral thigh starting 01/06/2026, as well as an order for triple antibiotic ointment to the right buttock starting 11/19/2025. Review of the January 2026 Treatment Administration Record (TAR) showed no documentation on the night shift for the ordered right buttock wound care, left buttock wound care, right lateral thigh wound care, or the triple antibiotic ointment on 1/9/2026 and 1/10/2026, despite the orders being active on those dates. During interviews, the Director of Nursing stated that an empty space on the TAR means either the nurse did not perform the wound care or forgot to document it, and that nurses are expected to document wound care when completed. One LPN reported always performing the resident’s wound care and stated that wound care was completed on January 9 but was probably not charted. Another LPN stated that wound care was performed on January 10 but was not documented. The facility’s documentation policy, revised in January 2024, requires that services provided to residents be documented in the medical record and that documentation be complete and accurate, which was not followed in this case.
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