Failure to Maintain Complete Medical Records for Wound Care Visits
Penalty
Summary
The facility failed to maintain up-to-date and complete medical records for three residents who were receiving wound care from an outside wound consultant group. For each of these residents, documentation of wound physician visits was missing from their medical records, despite evidence that such visits had occurred. Specifically, one resident with multiple diagnoses, including a recent open wound and sepsis, had no wound physician visit notes in her closed record, and the DON confirmed that these notes were not present and would need to be obtained from the facility wound nurse. Another resident admitted with a skin alteration also had no wound physician visit documentation in the record, which was verified by the facility wound nurse, who acknowledged that the notes should have been uploaded after each visit. A third resident with several chronic conditions and a skin alteration on admission similarly lacked wound physician consultant notes in the medical record, with the regional nurse confirming that the notes were only accessible on the consultant's server and had not been uploaded as expected. These deficiencies were identified through interviews and record reviews, which revealed that the facility did not ensure that wound care documentation from external consultants was consistently incorporated into the residents' medical records. The expectation, as stated by facility staff, was that the wound nurse would upload these notes after each visit to keep the records current and complete for ongoing care. The absence of these records was discovered incidentally during a complaint investigation.