Failure to Document and Maintain Wound Care Orders and Treatments
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical documentation and wound care orders in accordance with its own policies and accepted professional standards. The facility’s Charting and Documentation policy required that all services provided, progress toward care plan goals, and changes in condition be documented in the medical record, and the Wound Care policy required documentation of the date and time wound care was given. The facility assessment indicated it would provide care for skin ulcers and injuries. Despite these requirements, surveyors identified multiple instances where wound care orders were missing or delayed and where ordered treatments were not documented as completed on the treatment administration records (TARs). For one resident with heart failure and chronic kidney disease who had an abscess on the right knee and a new wound on the right medial knee, a wound nurse practitioner ordered gentamicin ointment for both wounds, with the abscess to be changed daily and the medial wound twice daily. However, there was no physician’s order entered for the right medial knee wound until several days after the NP note, and the existing order for the right knee abscess was discontinued with no new order until the same later date. The TAR for the right medial wound also lacked documentation of completed dressing changes on multiple specified dates and times. Another resident, cognitively intact with hypertension and cellulitis and care-planned for potential pressure ulcers, had a physician’s order for twice-daily dressing changes to the left second toe, but the January TAR showed missing documentation of completed dressing changes on several evenings and mornings. This resident stated that he did not know what the staff’s problem was and expressed that it seemed like they did not care. A third cognitively intact resident with diabetes, necrotizing fasciitis, and gangrene, care-planned for actual/potential skin integrity impairment, had an order for twice-daily dressing changes to the left heel. The January TAR lacked documentation of completed dressing changes on multiple specified dates and times. This resident indicated that sometimes she had to remind staff and that if she did not ask or did not get a certain nurse, the dressing changes did not get done. A fourth resident with diabetes and cerebral palsy, care-planned for an actual pressure ulcer and with physician’s orders for daily coccyx dressing changes, also had multiple dates on the January TAR where the dressing changes were not documented as completed. The Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to appropriately document wound care orders and treatments for four of seven reviewed residents, in violation of state clinical records requirements.
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