Failure to Maintain Accurate and Complete Clinical Records for Wound Care
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible clinical records for one resident with a right heel pressure ulcer. The resident's diagnoses, care plan, and physician orders included specific instructions for wound care and offloading of the affected heel. Wound care consultation appointments documented clear recommendations to hold off on weight-bearing physical therapy (PT) until the wound healed and to use specialized offloading devices. However, these recommendations were not transcribed into the resident's medical record or communicated to the PT staff in a timely manner. Despite the wound care provider's instructions, physical therapy documentation over several weeks continued to list the resident as weight bearing as tolerated on the right lower extremity, and the resident participated in ambulation activities. The resident repeatedly reported to PT staff that he was instructed by his doctor to avoid weight bearing and remain in bed, but nursing staff indicated that no such orders were present in the record. This discrepancy persisted until the recommendations from the wound care consultations were finally received and entered into the record, and PT staff were made aware of the restrictions. Interviews with facility staff, including the Director of Rehabilitation and the DON, confirmed that the wound care provider's recommendations were not transcribed into the electronic medical record or communicated to the appropriate staff upon the resident's return from appointments. The lack of timely transcription and communication resulted in incomplete and inaccurate clinical records, as well as a failure to ensure that all staff were aware of and following the current care instructions for the resident.