Incomplete and Inaccurate Documentation of Wound Care in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident receiving wound care. The resident was an elderly male with dementia, surgical aftercare for the digestive system, HTN, muscle wasting, lymphedema, and DM, who was admitted with no cognitive impairment per BIMS and was totally dependent for transfer and mobility. His care plan included wound care for pressure ulcers, notifying the MD of changes, following treatment orders, use of a pressure-relief mattress, and nutritional supplements and proteins. Physician orders for March included wound care to the great toes bilaterally every shift, to the left and right heels on Tuesday/Thursday/Saturday, and to the sacrum every shift and PRN. Record review of the March Treatment Administration Record (TAR) showed multiple dates where ordered wound care was not documented. For the great toes, wound care was not documented on several specified dates; for the heels, wound care was not documented on two specified dates; and for the sacrum, wound care was not documented on multiple specified dates. The ADON stated that the resident had lymphedema with swelling and oozing to both legs and confirmed the wound care orders, including additional orders for both legs on specific days and PRN. The ADON identified LVN B and LVN C as the nurses responsible for the wound care and acknowledged she could not explain why the physician-ordered wound care was not documented on the TAR on the identified dates. Interviews with facility staff revealed that wound care was reportedly performed on some of the dates where no documentation existed. The Regional RN stated that the lack of documentation on one date corresponded with the resident being in the hospital for observation after a fall, and reported that LVN B told him wound care was done but not documented on another date. LVN A reported witnessing LVN C provide wound care on one of the undocumented dates but was unsure if it was charted. LVN B admitted applying a wound patch on one date but forgetting to document it. The ADON reported monitoring wound care on another undocumented date and having a photo of the sacrum as proof care was done, and a text message from LVN C stated she performed wound care on three of the undocumented dates. The DON stated that, to her knowledge, wound care was provided on several of the dates in question but not documented, despite the facility’s policy requiring that all services provided and changes in condition be documented in the medical record.
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