Incomplete and Delayed Wound Documentation for Resident with Multiple Pressure Injuries
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete, accurately documented, and readily accessible, as required by facility policy and professional standards. Upon admission, the resident, who had a history of encephalopathy, diabetes, dementia, and rheumatoid arthritis, presented with multiple pressure injuries, including a Stage 4 pressure injury, several unstageable wounds, and deep tissue injuries. Although the facility's policy required a comprehensive skin assessment with measurements and detailed documentation upon admission, the initial assessment lacked critical information such as wound measurements, staging, etiology, and detailed descriptions. Additionally, the documentation did not specify the number or precise locations of wounds on the toes and feet. Treatment orders for the resident's wounds were not consistently documented as completed in the Treatment Administration Record (TAR) for several days following admission. Specifically, wound care orders for the right lower extremity, coccyx, right hip, and left foot and toes were not signed out as completed on multiple dates. The comprehensive assessment of the resident's pressure injuries was not performed until three days after admission, contrary to facility policy and expectations for timely assessment and documentation. The lack of timely and complete documentation hindered the ability to track wound progression and ensure appropriate care. When concerns were raised by the surveyor, the facility provided handwritten wound logs and assessment forms that were not part of the formal medical record and lacked essential information such as the identity of the person documenting and specific dates. These documents were only submitted after the surveyor's inquiry and were not originally included in the resident's official medical record. The incomplete and delayed documentation, as well as the absence of required information in the medical record, constituted a failure to safeguard resident-identifiable information and maintain accurate medical records in accordance with accepted professional standards.