Inaccurate Documentation of Compression Stocking Application
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including hemiparesis, cerebral infarction, congestive heart failure, and chronic ischemic heart disease, did not have accurate documentation in their medical record regarding the application of compression stockings. The resident required significant assistance with activities of daily living and had an order for compression stockings to be applied to both lower legs for skin integrity. The treatment record indicated that the compression stockings were documented as applied on a specific date and time. However, direct observations at three different times on the same day revealed that the compression stockings were not applied to the resident. During an interview, an RN confirmed that the compression stockings had not yet been applied but acknowledged that he had already signed off in the treatment record as if the application had been completed. The Director of Nursing stated that her expectation was for treatments to be signed off only after they were completed.