Inaccurate Documentation of Adaptive Device Use for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure accurate care documentation for a resident receiving pressure ulcer care. A physician's order directed that foam adaptors be applied at meal times to promote optimum intake and independence. However, review of the Medication Administration Record showed that nursing staff documented the use of the adaptive device for each shift over a nine-day period, despite the device not being available to the resident during that time. Direct observation confirmed the resident ate dinner without the adaptive utensils, and both the resident, their spouse, and the therapy director verified that the device had not been available for the past week. The therapy director also stated the device was supposed to be stored at the resident's bedside. The unit manager acknowledged and confirmed the deficiency during an interview.