Inaccurate Documentation of Pressure Injuries on Weekly Summary
Penalty
Summary
The facility failed to ensure accurate and concise documentation of a resident's skin condition on the Weekly Summary Documentation (WSD) dated 4/17/2025. Despite the resident having multiple documented pressure injuries—including a stage 3 pressure injury on the left buttock and deep tissue injuries (DTIs) on both heels, as confirmed by the Treatment Administration Record (TAR) and the wound care doctor's Weekly Wound Assessment (WWA)—the WSD incorrectly indicated that the resident had no skin issues. This error was acknowledged by the LVN who completed the WSD, stating that the section for skin integrity was checked incorrectly and should have reflected the presence of skin problems. The resident involved had a complex medical history, including a hip fracture, left artificial hip joint, and a history of falls, and was assessed as severely cognitively impaired and fully dependent for all activities of daily living. The discrepancy in documentation was identified during interviews and record reviews, with the Director of Nursing (DON) confirming that the WSD was inconsistent with other clinical records. Facility policy requires nursing documentation to be clear, accurate, and reflective of the resident's condition, but this was not followed in this instance, potentially impacting the monitoring and care of the resident's wounds.