Incomplete Medical Record Documentation for Pressure Ulcer Diagnosis
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically by not adding a new diagnosis of a sacral pressure ulcer to the resident's electronic medical record (EMR) profile. The resident, an older male with multiple complex medical conditions including atrial fibrillation, hypertension, diabetes, and a history of falls, was assessed as being at risk for pressure injuries and had at least one pressure injury documented. Despite this, the new diagnosis of a sacral wound, identified on 03/31/25, was not entered into the EMR by the MDS Coordinator or other responsible staff. Interviews revealed that the MDS Coordinator was aware of the sacral wound but had not updated the EMR profile to reflect this diagnosis. The Administrator confirmed that there was no designated backup for adding diagnoses when the MDS Coordinator was absent, and acknowledged the importance of having accurate diagnoses in the EMR to reflect the resident's condition. Additionally, the facility did not have a written medical records policy available for review.