Failure to Accurately Document Pressure Ulcer Interventions
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for one resident with pressure ulcers. Specifically, for a resident admitted with multiple pressure ulcers, including Stage 3 and Stage 4 wounds, physician orders required that the resident's heels be floated and that the resident be turned and repositioned every two hours. However, a review of the resident's ADL flowsheets revealed missing documentation for these interventions on several shifts. The assigned CNAs did not record whether the required care was provided during these periods. Interviews with staff confirmed that CNAs were responsible for documenting all ADL tasks, including pressure ulcer interventions such as turning and floating heels. One CNA acknowledged that documentation was not completed for the specified dates, citing lack of computer access at times, but stated that care was provided. The Director of Nursing also confirmed that the documentation was incomplete and that the required interventions were not accurately recorded in the resident's medical record.