Failure to Accurately Document Skin Changes and Wound Care
Penalty
Summary
The facility failed to ensure that a resident's medical records were accurate and complete in accordance with accepted professional standards and practices. Specifically, for one resident with a history of diabetes and fluctuating decision-making capacity, the nursing weekly summary and skin evaluations did not reflect significant skin changes that occurred over a ten-day period. Documentation showed that the resident was seen by wound care specialists who identified and reclassified a sacral pressure wound and noted new deep tissue injuries (DTIs) on the right heel and right lateral malleolus, with new treatment orders issued. However, there were no corresponding skin and wound evaluations or updated measurements recorded on the dates when these changes were identified, as required by facility protocol. Additionally, the nursing weekly summaries during this period consistently indicated that there were no new skin changes or breakdowns, despite the documented findings and new treatment orders from the wound care team. Interviews with the LVN and DON confirmed that skin evaluations and documentation should have been completed to reflect the changes in the resident's condition, including wound descriptions and measurements. The facility's own policy required that all changes in a resident's medical condition be documented in the clinical record, but this was not done, resulting in incomplete and inaccurate medical records for the resident.