Inaccurate Documentation of Skin Assessments and Dressing Changes
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for two of five sampled residents, specifically regarding weekly skin assessments and dressing changes. For one resident with multiple complex diagnoses, including diabetes with foot ulcers and a traumatic amputation, weekly skin assessments were documented in the electronic health record for dates when the resident was actually hospitalized and not present in the facility. The LPN/treatment nurse confirmed that these entries were made in error and should not have been completed for a resident who was not in the facility. For another resident with a history of right femur fracture, congestive heart failure, hemiplegia, and dementia, the facility's records showed both a skin assessment and PEG tube dressing changes documented on dates when the resident was hospitalized and not present in the facility. The LPN/treatment nurse acknowledged that these assessments and treatments could not have been performed as documented, confirming the inaccuracy of the medical records for those dates.