Inadequate Burn Wound Assessment, Treatment Documentation, and Follow-Through
Penalty
Summary
Licensed nursing staff failed to provide wound care and documentation in accordance with professional standards for a resident who sustained first- and second-degree burns to the lower abdomen, groin, and right hip after spilling hot soup. Initial documentation on the day of injury described the burn locations, sizes, and blistering, and indicated that the provider evaluated the burns and gave instructions for new orders, including dressing applications. Subsequent nursing notes on selected days documented that the burn area was cleaned, Bacitracin applied, and dressings placed, with brief comments such as "no signs of infection" and that the resident tolerated treatment. However, these notes did not consistently address all burn areas or provide detailed assessments of the wounds, including classification, measurements, wound assessment, wound edges, odor, pain, or signs of infection, nor did they evaluate whether the treatment was beneficial. Record review showed multiple dates with no wound status notes, including several days immediately following the injury and a prolonged gap until the wound was later documented as resolved. The wound management nurse had left the facility unexpectedly, and the nurse who assumed wound responsibilities reported she was unaware of the resident’s wound until weeks later, when she first assessed it and found it resolved. The Medication Administration Record for the month showed that ordered daily dressing changes to the right lateral hip burn site were not documented as completed on eight of 21 days. The facility’s own wound treatment management policy required documentation of treatments and ongoing assessment of wound effectiveness, and professional standards cited by the American Nurses Association emphasized the need for clear, accurate, and accessible nursing documentation, which were not met in this case.
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