Incomplete and Inaccurate Medical Record Documentation for High-Risk Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, as required by professional standards and facility policy. Specifically, the resident, who had a history of hemiplegia and was at high risk for pressure ulcers due to impaired mobility and incontinence, had physician orders for twice-weekly skin checks and bathing, with documentation required by licensed nursing staff. However, a review of the resident's records for a period spanning over a year revealed no documented evidence that these skin checks were performed, despite the resident's high risk status and previous history of pressure ulcers. This lack of documentation was confirmed by the Director of Nursing. Additionally, nursing staff erroneously documented the presence and treatment of a pressure ulcer on the resident's left gluteal fold for ten days, when in fact the area was a healed scar and not an open wound. The care plan was also developed based on this incorrect assessment, citing non-compliance with care that was not supported by the ongoing documentation, which indicated the resident was being turned, repositioned, and bathed as required. These actions resulted in inaccurate and incomplete medical records, contrary to facility policy and accepted professional standards.