Incomplete Wound Assessment Documentation and Failure to Record Care Refusals
Penalty
Summary
The facility failed to maintain accurate and complete documentation of wound assessments and care refusals for one resident with a history of acute and subacute infective endocarditis. The resident's medical record showed gaps in weekly wound assessments, with no documentation between certain dates, and several assessments were incomplete, missing critical information such as wound measurements, descriptions, and wound type. Additionally, refusals of wound care by the resident were not documented in the medical record as required by facility policy. Interviews with nursing staff confirmed that wound assessments were not fully completed and that refusals of care were not consistently documented. Staff acknowledged that the assessment forms were not always filled out after wound care was provided, and that documentation of interventions and resident responses to refusals was lacking. These actions and omissions resulted in incomplete and inaccurate medical records for the resident.