Incomplete Wound Care Documentation and Unlabeled Dressings for Venous Leg Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and documentation of wound care for a resident with a venous leg ulcer. Facility policy on Skin and Wound Monitoring and Management required that wound care be implemented as ordered, with documentation in the Treatment Administration Record (TAR) reflecting the care provided and any wound changes. The resident’s care plan, revised in early June 2025, identified altered skin integrity due to a venous ulcer on the right leg and directed staff to perform treatments as ordered and to assess, record, and monitor wound healing. The resident’s Minimum Data Set showed they were cognitively intact and had multiple medical conditions, including heart and respiratory failure and unstable blood sugar, and that they received skin/wound treatment during the assessment period. During observations, the resident was seen with a white mesh dressing on the right lower leg that was secured with tape and showed scant drainage, but the dressing was unlabeled with no date or staff initials. In a later observation and interview, the dressing remained unlabeled, and the resident reported they were sure the dressing had not been changed that day, though they could not recall the exact date of the last change. A registered nurse stated they changed the dressing every other day as ordered but acknowledged they did not date or initial the dressing after changes. Review of the resident’s February 2026 TAR showed that on three specific dates the ordered right leg wound dressing change was not signed off and the entries were left blank. The administrator and the infection preventionist/staff development nurse confirmed their expectation that nurses date and initial dressings for auditing and that staff follow physician wound treatment orders and document the care provided in the medical record.
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