Inaccurate and Incomplete Wound Documentation for Residents with Skin Integrity Issues
Penalty
Summary
The facility failed to ensure that clinical records were accurate and maintained according to accepted professional standards for two residents with wounds. For one resident, there were significant gaps and inconsistencies in the documentation of weekly skin assessments and wound observations. The resident was admitted with multiple pressure ulcers and moisture-associated skin damage, but the required weekly skin assessments were either missing, marked as refused without follow-up, or left blank for extended periods. Wound observation tools were not completed at the required frequency, with some assessments delayed by several weeks. Observations and interviews confirmed that the documentation did not consistently reflect the resident's actual wound status or the care provided. Another resident with multiple chronic conditions, including multiple sclerosis and malnutrition, also had inconsistent and unclear documentation regarding skin integrity. Weekly skin checks noted open areas on the coccyx, but there was a lack of detailed wound notes or measurements for an extended period. The care plan indicated the presence of a pressure ulcer and follow-up by a wound care clinic, but the medical record did not contain corresponding wound documentation during a critical month. Staff interviews revealed that a new nurse was responsible for some of the incomplete documentation and that there was confusion and inaccuracy in the records related to the resident's skin condition. The facility's own policies required weekly head-to-toe skin inspections and timely, detailed documentation of any wounds or skin alterations. However, the records reviewed showed multiple instances where these requirements were not met, including late entries, missing assessments, and lack of clear wound descriptions. These documentation failures resulted in clinical records that did not accurately reflect the residents' conditions or the care provided, as confirmed by staff interviews and record reviews.