Failure to Accurately Document Physician-Ordered Wound Care Treatments
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical records and document wound care treatments as ordered for three residents with pressure injuries or risk for pressure injuries. For one resident, an elderly female with severe cognitive impairment, dementia, Alzheimer’s disease, stroke, and malnutrition, the MDS and care plan showed she was dependent on staff for repositioning and incontinent care, with identified risk for pressure ulcers. Her care plan interventions included heel offloading, turning and repositioning at least every two hours, and assistance with bed mobility, dressing, and toileting. However, review of her Treatment Administration Record (TAR) for a specified month showed multiple dates on which her scheduled wound care was not documented as given. A second resident, an elderly male with moderately impaired decision-making, heart failure, malnutrition, muscle weakness, difficulty walking, and end-stage renal disease, was also always incontinent and required maximal assistance with toileting hygiene. His care plan documented that he had a pressure ulcer or risk for pressure ulcer development, with goals for intact skin and interventions including administering medications as ordered, following facility skin breakdown protocols, providing incontinence care after each episode with moisture barrier, and notifying nursing of any new skin issues. His February TAR similarly showed numerous dates where his scheduled wound care was not documented as completed. A third resident, an elderly female with intact cognition and diagnoses including type 2 diabetes, difficulty walking, muscle weakness, heart failure, and protein-calorie malnutrition, was always incontinent and dependent on staff for toileting. Her care plan identified potential for pressure ulcer development and decreased mobility, with goals for intact skin and interventions including following facility skin breakdown prevention protocols and assisting with turning and repositioning at least every two hours. Her February TAR also showed several dates with no documentation of scheduled wound care. In interviews, the ADON, DON, and Administrator each stated that the expectation was that staff document completed wound care at least once per shift, and that if wound care was not documented in the electronic health record, it was considered not done, even though staff might have performed the care and forgotten to chart it. The facility’s pressure injury policy required the treatment nurse or designee to sign off on the treatment sheet for any treatment completed, which was not consistently reflected in the records reviewed.
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