Failure to Accurately Document Physician-Ordered Wound Treatments on TAR
Penalty
Summary
The deficiency involves the facility’s failure to accurately document physician-ordered wound treatments on the Treatment Administration Record (TAR) for multiple residents, contrary to its own policies requiring concise, clear, and accurate nursing documentation. For one resident with anemia, diabetes, and lung disease, physician orders directed daily and PRN dressing changes to a right posterior buttocks wound and a right foot wound. The March TAR for this resident showed blank documentation entries for both wound treatments on a specific date. Observations showed the right leg and foot dressing dated two days prior, while the coccyx dressing was dated the day before, and the wound nurse who worked the prior night reported last changing the right foot dressing two days earlier. Another resident with anemia, hyponatremia, hip fracture, malnutrition, and lung disease had a physician order for daily or PRN sacral wound care. Observation showed the sacral bandage dated the previous day, and review of the March TAR revealed multiple blank entries for the sacral wound, including no documentation of a dressing change on the date corresponding to the bandage date. A third resident with anemia, renal disease, stroke, malnutrition, and lung disease had a physician order for daily and PRN wound care to the left inner thigh and left stump, but the March TAR showed one of three opportunities left blank. The facility’s Wound Management policy required weekly documentation of treatment effectiveness by an LPN or RN, and the Documentation – Nursing Policy prohibited falsification or improper correction of nursing documentation and required accurate, evidence-based charting. During interviews, one wound nurse stated there were no residents missing treatments and described a culture of clocking out after eight hours even if wound care was unfinished. The DON, Regional Nurse, and Administrator each stated they expected all treatments to be documented at the time they were completed, with nurses using computers on carts to chart in real time, but the TAR reviews and observations demonstrated missing or incomplete documentation of ordered wound treatments for three residents in the sample of five.
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