F0842

D

Incomplete Documentation of Ordered Wound Care on Treatment Administration Record

San Antonio, Texas Survey Completed on 02-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with professional standards for one resident receiving wound care. A 65-year-old female resident was admitted with pressure-related skin issues, including deep tissue injuries to both heels and, per a wound care assessment dated 02/02/2026, stage 2 pressure ulcers on the left and right buttocks. The comprehensive care plan dated 01/30/2026 addressed deep tissue injuries to the heels but did not include a care plan for the resident’s stage 2 pressure ulcers on the buttocks. A physician’s order dated 02/04/2026 directed daily application of triad with collagen particles to the stage 2 pressure ulcers on the left and right buttocks.

Review of the Treatment Administration Record (TAR) for 02/01/2026 through 02/28/2026 showed that the ordered wound care was not initialed as given on 02/01/2026, 02/07/2026, and 02/08/2026. LVN-B reported working on 02/01/2026 and providing the ordered wound care but stated she forgot to document it on the TAR. LVN-A reported working on 02/07/2026, providing the ordered triad with collagen particles once daily and leaving the area open to air, but also forgot to document on the TAR. RN-C reported working on 02/08/2026, providing the triad with collagen particles to the buttock pressure ulcers, but did not document because she did not consider applying cream with collagen particles to be wound care. The DON confirmed that applying triad with collagen particles to the stage 2 buttock ulcers was considered wound care and that nurses should have documented these treatments on the TAR, consistent with the facility’s documentation policy requiring licensed staff to document all services at the time of service or by the end of the shift.