Inaccurate Wound Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that medical records for two residents were accurately documented in accordance with accepted professional standards. For one resident, the Treatment Nurse documented in the wound assessment that a pressure ulcer was improving, while the Wound Care Nurse Practitioner (NP) documented on the same day that the wound was worsening. The Treatment Nurse later acknowledged making a mistake in the documentation. The resident had a history of diabetes, schizoaffective disorder, hypertension, and decreased mobility, and was at risk for skin breakdown. The care plan indicated the presence of a pressure ulcer, and the resident was receiving daily wound care and weekly assessments by the Wound Care NP. For another resident, the Treatment Nurse initially documented that a pressure ulcer was worsening, but after an audit, changed the assessment to indicate the wound was improving, despite the Wound Care NP's documentation that the wound was worsening. This resident had diagnoses including lack of coordination, diabetes, obesity, and pressure ulcers, and was moderately cognitively impaired. Interviews with the Wound Care NP and the Director of Nursing (DON) confirmed the expectation that nursing wound assessments should accurately reflect the NP's findings. The facility was unable to provide a policy regarding the accuracy of documentation.