Failure to Document and Maintain Accurate Wound Records
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was admitted with a surgical wound on the left hip. Upon admission, the responsible RN did not document the presence or description of the resident's left hip wound in the clinical admission record, despite the resident's history and physical indicating a healing wound and the Minimum Data Set noting the need for surgical wound care. The RN confirmed that wound assessments, including descriptions and measurements, should be documented at admission to allow for proper monitoring. Additionally, facility staff did not document the description or measurements of the resident's left hip wound in the long-term care evaluations on multiple subsequent dates. The Director of Nursing acknowledged that staff should have included this information in the evaluations. The facility's policy requires that documentation in the medical record be objective, complete, and accurate, but this was not followed, resulting in incomplete and inaccurate records for the resident.