Inaccurate Medical Assessment Documentation for Resident
Penalty
Summary
The facility failed to ensure the accuracy of medical assessment documentation for a resident. A review of the resident's medical record revealed a skilled progress note by an LPN documenting the presence of sacral wounds. However, subsequent reviews of the Treatment Administration Record (TAR) for the same period showed that multiple nursing staff consistently documented the resident's skin as intact during weekly and twice-weekly assessments. No additional documentation or evidence of sacral wounds was found in the resident's medical record. Interviews with the Assistant Director of Nursing (ADON) and a Registered Nurse (RN) confirmed that the resident did not have any sacral wounds, and the ADON acknowledged that the earlier documentation was incorrect. The Director of Nursing (DON) also confirmed that the documentation was entered in error and should be removed from the resident's chart. The deficiency was identified during the survey process as a result of these inconsistencies in the resident's medical documentation.