Incomplete Treatment Administration Records for Ordered Catheter and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate Treatment Administration Records (TARs) for ordered treatments and care. For one resident with obstructive uropathy and benign prostatic hyperplasia who had an indwelling urinary catheter, the physician’s orders required that the catheter bag be kept covered, maintained below bladder level, kept off the floor, and emptied every shift, as well as catheter care every shift. Review of the TAR for December showed multiple shifts where documentation for these catheter-related treatments was left blank, including specific evening and night shifts, despite the resident having an ongoing catheter and reporting that staff had taken good care of it. For another resident with heart failure, diabetes, cellulitis of the right lower leg, and an above-knee amputation, the physician had ordered multiple skin, wound, and catheter-related treatments, many of them scheduled every shift or on specific days of the week (Mondays, Wednesdays, and Fridays). These orders included application of zinc oxide ointment to the coccyx, catheter care every shift, monitoring for neurogenic bladder symptoms every shift, cleansing and dressing of lower back skin tears, and various wound care treatments to the left thigh, hip, ischium, coccyx, and left lateral foot, including use of Medihoney, collagen, hydrocolloid, and wound vac dressings. The November TAR showed numerous blanks where these treatments and monitoring were to be documented on specified day, evening, and night shifts. During an interview, the DON stated that the documentation on the TARs should have been completed. The facility’s undated “Charting and Documentation” policy, identified by the DON as current, states that all services provided to residents shall be documented in the resident’s medical record. The survey findings concluded that, for two of three residents reviewed, the facility failed to ensure that documentation of ordered treatments and services was completed on the TARs, resulting in incomplete medical records in violation of the facility’s own documentation policy.
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