Inaccurate Medical Record Documentation for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure complete and accurate medical records for one of three residents reviewed for pressure ulcer care. A physician's order was in place for the use of skin prep on a resident's left great toe pressure injury, and the resident's medical record documented an allergy to betadine. However, the wound nurse practitioner's weekly notes on three separate occasions incorrectly documented that the pressure ulcer was being treated with betadine instead of the ordered skin prep. This documentation error persisted until subsequent notes correctly reflected the use of skin prep. The Director of Nursing confirmed that the nurse practitioner's documentation was inaccurate regarding the treatment used for the resident's pressure ulcer, despite the known allergy.