Failure to Accurately Document and Maintain Resident Medical Record
Penalty
Summary
The facility failed to ensure the accuracy and integrity of a resident's medical record, specifically regarding the documentation of a pressure ulcer. A resident with multiple diagnoses, including cancer and impaired mobility, was at risk for pressure ulcers and had interventions in place to prevent skin breakdown. On a specific date, a CNA discovered a dark, discolored area on the resident's right heel, which was assessed by an LPN who took a photo and notified the resident's daughter and the DON. Despite this, there was no documentation in the medical record or wound assessment on the day the area was first identified. Subsequent nursing notes falsely indicated that the resident had no skin impairments prior to leaving for an appointment and that the pressure ulcer was only discovered upon her return, classifying it as community-acquired. Interviews revealed that the LPN, under the impression from the DON's comments, did not document the wound when it was first found and later falsified the record to reflect the wound as new upon the resident's return. The DON and wound nurse confirmed that the area was present earlier and that the medical record did not accurately reflect the timeline of the wound's discovery. The investigation confirmed that the facility did not maintain accurate and timely documentation of the resident's skin condition, and the wound was not properly assessed or recorded when first identified. Orders for treatment were obtained, but the lack of documentation and the subsequent falsification of records led to an inaccurate medical record for the resident.