Incomplete Documentation of Pressure Ulcer in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a history of leg fracture, dementia, and malnutrition. The resident was identified as being at risk for pressure ulcers, and a pressure ulcer to the right buttock was discovered. However, the weekly skin assessment did not document the presence of this wound, despite other records, such as the care plan, physician orders, and wound care notes, indicating its existence and treatment. The omission was confirmed during interviews, where the nurse responsible for the assessment could not recall the wound and admitted to possibly forgetting or being confused when completing the documentation. Further review revealed that the Director of Nursing acknowledged the documentation error, attributing it to staff not paying attention or possibly copying previous documentation without conducting a proper assessment. The facility's policy requires that each resident's medical record accurately reflect their actual experiences and provide enough information to depict their progress, which was not met in this instance.