Inaccurate Documentation of Wound Care in Medical Records
Penalty
Summary
Surveyors found that the facility failed to accurately document wound care for one resident with peripheral vascular disease, anxiety, and depression, who had moderately impaired cognition. The resident was observed on multiple occasions with a soiled dressing on the right ankle, dated several days prior, which only partially covered an open wound and showed signs of drainage. Despite this, the Medication Administration Record (MAR) indicated that dressing changes had been documented as completed on three consecutive days. Interviews with nursing staff confirmed that the dressing had not been changed as recorded, and the Director of Nursing acknowledged the expectation for accurate documentation but could not provide a facility policy on the matter. The discrepancy between the observed condition of the dressing and the MAR entries demonstrated a failure to maintain accurate medical records in accordance with professional standards.