Failure to Maintain Accurate Clinical Records and Wound Care Documentation
Penalty
Summary
Facility staff failed to maintain a complete and accurate clinical record for one resident, resulting in multiple documentation and assessment deficiencies. The staff did not complete accurate weekly skin assessments before and after the identification of a pressure sore, and failed to document accurate Braden scale assessments upon admission and after the discovery of an unstageable pressure sore. Additionally, the presence of the pressure ulcer was not consistently or accurately documented in skilled nursing and physician progress notes, with some notes indicating no wound after the ulcer had been identified. The resident involved had a complex medical history, including acute stroke with craniotomy, paralysis, dysphagia with PEG tube, diabetes, chronic kidney disease, cardiomyopathy, and other significant conditions. The resident was dependent on staff for all activities of daily living and was at high risk for pressure ulcer development. Despite this, Braden risk assessments were only completed twice and both were done late. The initial wound treatment orders lacked proper documentation regarding who ordered the treatment and did not include wound evaluations, assessments, or measurements until eight days after the wound was first identified. There were also significant gaps in wound care documentation and treatment administration. No skin assessments were documented until the wound care nurse evaluated the resident, and there were periods where no treatment orders were in place for the sacral wound. Treatment administration records showed multiple missed treatments, and the facility's policy requiring weekly skin assessments was not followed. The lack of consistent and accurate documentation, assessment, and treatment monitoring contributed to the deficiency identified by surveyors.