Inaccurate Documentation of Wound Location in Resident Record
Penalty
Summary
The facility failed to accurately document the correct extremity involved in the weekly wound evaluation summary for one resident. Specifically, a resident who was admitted with cellulitis in the lower extremities and sepsis had a wound on her left heel, as confirmed by physician orders and the resident's own statement. However, the facility's weekly wound evaluations on two separate occasions incorrectly identified and measured the wound as being on the right heel instead of the left. This documentation error was confirmed during interviews with both the wound Treatment Nurse and the Director of Nursing, who acknowledged that the records were inaccurate and could confuse readers. The facility's own policy requires that all wounds and treatments be accurately documented in the resident's record, but this was not followed in the case of this resident.