Incomplete Documentation of Wound Care and Assessments
Penalty
Summary
Surveyors identified that the facility failed to maintain complete, accurate, and accessible medical records for three residents with significant medical needs, including pressure ulcers and tracheostomies. The facility's policy required nursing staff to perform and document weekly skin assessments and wound care in the electronic medical record, including details such as who performed the care and when it was completed. However, record reviews revealed that for all three residents, there were multiple days where there was no documented evidence that wound treatments were administered as ordered, nor any documentation of resident refusal. For one resident with a history of stroke, paraplegia, and a neurogenic bladder, physician orders required daily wound care for a sacral pressure ulcer. Over a two-month period, documentation was missing for 38 out of 61 days, and when wound care was recorded, it lacked information on the time and the staff member who performed the treatment. Another resident with a history of stroke, hemiplegia, and chronic kidney disease had orders for multiple wound treatments, but documentation was missing for 25 out of 57 days, with no evidence of refusals or identification of the staff providing care. A third resident, admitted with a tracheostomy, ventilator dependence, and a sacral pressure ulcer, had no documentation of daily wound care on 20 of 22 days reviewed, nor evidence of weekly skin assessments as required by the care plan. Interviews with nursing staff and management confirmed that wound care and assessments should be documented in specific areas of the electronic medical record, and that the work list was used to track completion. However, the documentation system did not consistently capture who performed the care or the time it was completed, and in many cases, there was no documentation at all. The Assistant Director of Nursing acknowledged the lack of documentation and was unable to explain the missing records for the reviewed dates.