Incomplete Documentation of Wound Care and Bathing
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate documentation of wound treatments and bathing in accordance with its own policies and accepted professional standards. Facility policies on Activities of Daily Living and Charting and Documentation require that residents who cannot perform ADLs independently receive appropriate hygiene care, and that all procedures and treatments be documented with date, time, and the signature and title of the person providing care. For one resident with cerebral palsy, chronic respiratory failure, and a gastrostomy, physician orders required wound dressings to the right ischium every morning and at bedtime, but the March 2026 treatment record lacked documentation of multiple ordered dressing changes. The same resident’s bathing task, scheduled for specific days on day shift, also lacked documentation that baths were provided on several scheduled dates. Additional residents were affected by similar documentation gaps. One resident with hypertension, COPD, and lumbar spine fusion had an order for a daily coccyx wound dressing on day shift, but the March 2026 treatment record lacked documentation of numerous dressing changes, and the bathing task, scheduled for specific evenings, lacked documentation of several baths. Another resident with chronic respiratory failure, multiple sclerosis, and hypertension had missing documentation for several scheduled baths. A resident with diabetes and quadriplegia had multiple scheduled baths without corresponding documentation. A fifth resident with spina bifida, anxiety, and diabetes had physician orders for daily wound dressings to the left ischium and right sacrum, but the March 2026 treatment record lacked documentation of several of these treatments. In an interview, the Nursing Home Administrator in training confirmed that the clinical records for all five residents did not contain complete documentation of wound dressing changes and/or showers and acknowledged that these should be done as ordered and documented when completed.
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