Failure to Accurately Document Wound Care Treatments on TARs
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for two residents receiving wound care, as required by professional standards and facility policy. For Resident #1, who had multiple complex medical conditions including severe sepsis, pressure ulcers (including a stage 3 sacral wound and unstageable coccyx ulcer), and significant functional and cognitive impairment, the Treatment Administration Record (TAR) for February 2026 showed no documentation of wound care on 02/16/2026. The resident’s care plan required observation and documentation of skin injury location, size, and treatment, as well as provision and documentation of wound treatments and weekly measurements. For Resident #2, who had a cutaneous abscess of the abdominal wall and was at risk for pressure ulcers, the TAR for February 2026 lacked documentation of wound care on 02/15/2026, 02/16/2026, and 02/17/2026. This resident’s care plan required monitoring and documentation of the abdominal skin abscess, including location, size, treatment, and reporting of abnormalities or signs of infection. Skin measurement assessments dated 02/12/2026 and 02/18/2026 showed decreasing wound size with no concerns noted, but there was no corresponding TAR documentation for the three specified dates. In interviews, LVN A stated she completed wound care for Resident #1 on 02/16/2026 after being notified by the treatment nurse that the care needed to be done, but acknowledged she likely forgot to document the completed treatment on the TAR or in a progress note. RN A stated she completed wound care for Resident #2 on 02/15/2026 through 02/17/2026 but did not document it because she was unfamiliar with how to chart on the TAR. The DON confirmed that both nurses should have documented the wound care in the TAR or progress notes and that the facility’s policy requires documentation of treatments or services performed in the resident medical record.
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