Failure to Document Wound Care Treatment on MAR
Penalty
Summary
The facility failed to maintain complete and accurate clinical records when a nurse did not document wound care treatment on a resident’s medication administration record (MAR) for a scheduled treatment date. The resident was an elderly female with encephalopathy, dementia, short- and long-term memory deficits, and severely impaired cognitive skills, and had two Stage III pressure injuries to the left medial foot (inferior and superior). Her care plan, initiated in 2023 and revised in 2025, included interventions for pressure ulcer prevention and treatment, including administering wound treatments as ordered and monitoring for effectiveness. The December 2025 MAR contained physician orders for wound care to both left medial foot pressure injuries three times weekly and PRN on the day shift, with documented initials on multiple dates throughout the month. Record review showed that for both wound care orders, the MAR entries were blank on 12/26/2025, indicating no documentation of treatment on that date. LVN A explained that when wound care is completed, the nurse signs the MAR, and a blank entry could indicate the treatment was not completed; she confirmed she provided wound care on an earlier date but was unsure if she was assigned to the resident on 12/26/2025. The treatment nurse stated she completed the resident’s wound care on 12/24/2025 and was off on 12/26/2025, and that charge or administrative nurses were responsible for wound care when she was off. LVN N, the staffing coordinator, stated she provided wound care to the resident on 12/26/2025 following the MAR orders but forgot to document the treatment, realized this after going home, was unable to access the record remotely, and then forgot to update the MAR the following day. The DON stated that when the treatment nurse is not scheduled, the charge nurse is responsible for wound care and that the nurse who completes the treatment must sign the MAR by the end of the shift, consistent with the facility’s documentation policy requiring completion of MAR/TAR entries with each medication or treatment.
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