F0842

D

Incomplete and Inaccurate Wound Care Documentation on TAR

Las Cruces, New Mexico Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records related to wound care treatments for two residents. For one resident with a physician’s order dated 01/15/26 for daily wound care to the right buttock using normal saline, Medihoney, calcium alginate gauze, and a silicone bordered dressing, the Treatment Administration Record (TAR) for January 2026 showed no documentation that wound care was completed on 01/19/26, 01/21/26, and 01/23/26. For another resident with a physician’s order dated 01/01/26 for wound care to bilateral buttocks, including cleansing with normal saline, application of Sureprep to surrounding tissue, Medihoney to the wound bed, and coverage with a sacral silicone bandage, the January 2026 TAR contained no documentation of wound care from 01/02/26 through 01/23/26.

During an interview on 02/20/26, the Wound Care Nurse stated she worked Monday through Friday and completed all wound care on those days. She reported that she did perform wound care for the first resident on 01/19/26, 01/21/26, and 01/23/26 but did not document these treatments on the TAR. She also stated she completed wound care for the second resident on 01/01/26, 01/02/26, 01/05/26 through 01/09/26, 01/12/26 through 01/16/26, and 01/19/26 through 01/23/26, but again did not document these treatments on the TAR. The Wound Care Nurse indicated that sometimes the unit nurse documented completion of wound care on the TAR, and acknowledged she should ensure that either she or the unit nurse documented the wound care as completed. The survey findings state that this failure to accurately document wound care had the potential to negatively impact the care staff provide due to inaccurate records.