Failure to Provide Ordered Wound Care and Falsification of Treatment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered wound care and accurate documentation for a resident with a non-pressure skin tear on the right lower extremity. The resident had diagnoses including metabolic encephalopathy, repeated falls, and unspecified dementia, and was identified as having intermittent confusion, being chairbound, incontinent, and having balance problems. A physician’s order on the Treatment Administration Record (TAR) directed that the right lower extremity skin tears be cleansed with normal saline, patted dry, covered with xeroform and an ABD pad, and wrapped with gauze every two days on the night shift, beginning on 6/7/25. The TAR showed that wound care was documented as completed on 6/7, 6/9, 6/11, 6/13, 6/15, and 6/17/25. However, on 6/19/25, the DON identified that the dressing on the resident’s right lower extremity was still dated 6/11, indicating that the ordered dressing changes had not actually been performed for eight days despite documentation to the contrary. The DON confirmed that two nurses had signed that the dressing changes were completed on 6/13, 6/15, and 6/17, and the surveyor determined that this documentation was false. Weekly skin evaluations documented that the resident’s skin was not intact and that the areas were not new, but there was no further information in the progress notes about the appearance of the wound or the dressing. The resident’s care plan identified risk for skin breakdown related to assistance needs with bed mobility and repositioning, nutritional risk, and prior skin tears, and included interventions such as treatments as ordered, weekly skin checks by licensed staff, and observation of skin condition during routine care. The care plan did not instruct staff to limit skin checks to only new areas, yet the DON stated that staff performing weekly skin checks were focused on identifying new issues and did not pay attention to the date on the existing dressing. Facility policies on abuse, neglect, wound treatment management, and documentation required that ordered treatments be provided as prescribed, that neglect be prevented, and that documentation be factual, accurate, and not false. Despite these policies, the ordered wound treatments were not provided for eight days, and the medical record contained false entries indicating that wound care had been completed as ordered.
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