Incomplete Medical Record Documentation for Wound Care and ADLs
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who required wound treatments, had significant weight loss, and needed assistance with activities of daily living (ADLs). Nursing staff did not consistently complete required weekly wound logs and weekly nursing skin review assessments in the electronic health record (EHR) as mandated by facility policy. Specifically, there were missing entries for the weekly nursing skin review and several weekly wound logs, with staff interviews confirming that these assessments were not documented in the EHR, even though some information was recorded on paper forms that were not considered part of the official medical record. Further deficiencies were identified in the documentation of wound care treatments on the Treatment Administration Record (TAR). Several wound treatments were left unsigned on multiple dates and shifts, resulting in blank spaces on the TAR. Nursing progress notes indicated that some treatments were not administered because the resident was out of bed, but the documentation was vague and did not clarify whether treatments were re-attempted or if education was provided to the resident. Staff interviews confirmed that the lack of documentation meant it was unclear if the treatments were performed as required. Additionally, the Certified Nurse Aide (CNA) ADL flow sheets for several months contained numerous blank entries for essential care tasks such as oral hygiene, nutrition (fluid intake), and nutrition (amount eaten). CNAs and nursing staff acknowledged that documentation was expected to be completed by the end of each shift and that blank spaces indicated the required documentation was not done. The expectation was for floor nurses to review CNA documentation at the end of each shift, but this oversight did not occur, resulting in incomplete records for the resident's daily care.