Incomplete Documentation of Ordered Wound Treatments in MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident with multiple pressure ulcers and complex wound care needs. The resident was an elderly male with diagnoses including essential hypertension, dysphagia, edema, severe cognitive impairment (BIMS score of 3), and multiple pressure ulcers on the left distal medial foot, left lateral foot, right hip, left hip, coccyx, and sacrum related to reduced mobility. Physician orders directed specific wound treatments to the coccyx, sacrum, left distal medial foot, left lateral foot, and left hip, including the use of zinc oxide, Dakins solution, normal saline, alginate calcium, and dressings at prescribed frequencies. Record review of the Medication Administration Record (MAR) showed that on one date, wound treatments ordered three times every shift for the coccyx and sacrum were not signed off by an RN for the 7:00 PM and 11:00 PM times, and daily wound treatments for the left distal medial foot, left lateral foot, and left hip were not signed off for the 7:00 AM–7:00 PM period. On another date, the coccyx and sacrum treatments ordered three times every shift were not signed off by a different RN for the 7:00 PM time. The DON and ADM both stated that the expectation was for nurses to sign off in the electronic MAR (Matrix) once treatments were completed, and that an unsigned MAR entry would indicate the treatment was not completed. In interviews, the wound care doctor reported visiting weekly, debriding the resident’s foot on a mid-month date, and finding exposed bone, after which the resident was sent to the hospital for a higher level of care. The wound care doctor stated the resident had daily wound care treatments and that unsigned treatments on the identified dates would not have made the wounds worse, and he was not aware of any missed treatments. The resident’s responsible party stated the resident had been very sick, in and out of the hospital, and was sent out again for a change in condition, and she did not blame anyone for the resident’s health decline. RN A stated he provided all wound treatments on the identified date but did not sign them off because he was assisting with other nursing duties afterward, and acknowledged it was expected to sign off when treatments were completed and that lack of a signature would indicate the treatment was not done. RN B’s interview was initiated but not completed in the report excerpt. These findings demonstrate incomplete and inaccurate documentation of ordered wound treatments in the resident’s medical record.
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