Inaccurate Documentation of Pressure Injury Location
Penalty
Summary
The facility failed to ensure accurate documentation of a pressure injury for one resident. The resident, who had diagnoses including Type 2 Diabetes and urinary tract infections, was observed with a pressure-relieving boot on his right heel. Medical records and progress notes consistently indicated the presence of a pressure ulcer on the right heel. However, multiple weekly skin assessments documented open areas on the left foot or left heel, and some assessments did not specify which heel was affected. This inconsistency in documentation was not aligned with the resident's actual condition, as confirmed by both the RN and the DON, who stated that the resident only had a pressure ulcer on the right heel. The inaccurate documentation was identified through review of the resident's medical record and interviews with nursing staff. The facility's policy required accurate and organized documentation of all resident information in the medical record, but this was not followed in the case of this resident. The discrepancies in the skin assessments led to conflicting information about the location of the pressure ulcer, which was not corrected at the time of the survey.