Incomplete Clinical Records for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that clinical records were completed for a resident, identified as R82, who was admitted with multiple diagnoses including dementia, heart failure, type 2 diabetes, and acute kidney failure. The resident had a BIMS score of 6, indicating cognitive impairment, and was documented to have a Stage III pressure ulcer on the right buttocks and sacrum. The facility's policy required residents at risk of pressure injuries to be turned and repositioned regularly, with the frequency documented in the resident's plan of care. Despite the policy, there was no documented evidence that Resident R82 was turned and repositioned every 2-3 hours as required. Interviews with the Rehab Director and the Director of Nursing confirmed the absence of documentation for this task. The lack of documentation suggests that the facility did not adhere to its policy, potentially compromising the resident's care.
Plan Of Correction
A - CNAs assigned to Resident R82 were educated on completing documentation for turning and repositioning. B - Audited all residents with turn and repositioning programs to ensure documentation is being completed. C - All nursing staff educated on documentation requirements for turning and positioning in point of care. D - Weekly x 4 then monthly x 2 audits by DON or designee to ensure documentation of turning and repositioning in point of care is completed. Results discussed during QAPI meetings.