Inaccurate Documentation of Healed Pressure Ulcer
Penalty
Summary
The facility failed to maintain accurate and up-to-date medical records in accordance with accepted professional standards for one resident with a history of pressure ulcers. Specifically, nursing staff continued to document the presence of a right heel pressure ulcer in weekly body audits after the wound had been documented as healed. The clinical record showed that the right heel pressure ulcer, initially identified as Stage III, was resolved and wound care was discontinued, yet subsequent weekly body audits by nursing staff inaccurately described the wound as still present and requiring ongoing care. Interviews with facility staff confirmed the inaccuracy of the documentation. The Director of Nursing reviewed the resident's medical record and verified that the right heel pressure ulcer had healed, and any documentation after the healing date indicating the presence of the wound was incorrect. Additionally, a CNA stated that the resident no longer had any pressure injuries on his heels, further confirming the discrepancy between the resident's actual condition and the nursing documentation.