Failure to Accurately Document Ordered Wound Care Treatments
Penalty
Summary
The facility failed to ensure complete and accurate documentation of wound care treatments in the medical record for one resident. Resident #1 had a physician’s order dated 01/17/2026 for daily abdominal staple wound care with normal saline, pat dry, and application of a dry dressing on the day shift through 01/26/2026. Review of the Treatment Administration Record showed no documentation that the ordered abdominal wound care was completed on 01/18/2026, 01/19/2026, or 01/23/2026. In interview, one LPN stated she changed the resident’s abdominal dressing whenever she cared for the resident but acknowledged she must have forgotten to document the dressing changes on 01/18 and 01/23, while another LPN could not recall whether the dressing was changed on 01/19. The facility’s documentation policy requires clinical staff to document care and services in a manner that accurately reflects the clinical care provided and provides a complete account of the resident’s care, treatment, and response.
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