Inaccurate Medical Record Documentation for Resident with Amputation
Penalty
Summary
Facility staff failed to ensure the accuracy of a resident's medical record, as evidenced by conflicting documentation regarding the resident's condition. The electronic medical record indicated that the resident had a complete traumatic amputation of the left lower leg, while a skin assessment documented a left heel wound for the same resident. This discrepancy was identified during a review of the resident's records and confirmed through interviews with the Administrator, who stated that the admissions nurse is responsible for entering medical information based on the discharge summary, and the MDS Coordinator is responsible for checking the accuracy of the information entered. The deficiency was found during a recertification survey, where the inconsistency between the resident's diagnosis and wound documentation was observed and discussed with facility leadership.