Failure to Accurately Document Pressure Ulcer in Resident Assessment
Penalty
Summary
A resident with multiple medical conditions, including fractures, chronic kidney disease, diabetes mellitus, and edema, was admitted to the facility and identified as having a Stage 3 pressure ulcer on the sacrum upon admission. The resident's care plan included interventions for pressure ulcer management, and physician orders were in place for wound care treatments to be administered on specific days. Documentation in the Treatment Administration Record confirmed that the resident received the ordered wound treatments as scheduled. However, on one occasion, an LVN completed a nursing assessment and incorrectly documented that the resident had no wounds present, despite being aware of the existing pressure ulcer. This error in documentation was acknowledged by the LVN during an interview, who stated it was a mistake and recognized the importance of accurate record-keeping for continuity of care. The DON also confirmed that accurate documentation is a professional standard necessary for proper care delivery. The facility's policy requires that all treatments be administered based on written physician orders and that documentation be accurate.