Inaccurate Documentation of Pressure Injury Acquisition and Dates
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's clinical record regarding the date and acquisition of pressure injuries. Review of the resident's Minimum Data Set (MDS) and electronic medical record revealed inconsistencies in the documentation of pressure injuries to both heels. Initial assessments indicated the resident had intact skin, but a subsequent assessment documented unstageable pressure injuries and deep tissue injuries. The wound assessment note completed by the Wound Nurse Practitioner incorrectly stated that the wounds were not acquired in the facility and listed an inaccurate acquisition date. During interviews, the Director of Nursing (DON) confirmed that the wounds were acquired in the facility and were first noted on the same day the resident was transferred to the hospital. The DON acknowledged the discrepancy between her statement and the wound documentation. The Wound Nurse Practitioner later admitted to the documentation error and confirmed that an addendum was written to correct the information. The inaccurate documentation of wound acquisition and dates led to the deficiency cited during the complaint survey.