Incomplete Documentation of Staple Removal Procedure
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who was admitted with multiple fractures, including those of the left ulna, humerus, and pubis, following a fall. The resident had surgical wounds with staples in the left upper arm and wrist. Medical orders were present to remove the staples, and documentation indicated that the removal was authorized and signed off in the electronic medical record. However, there was no documentation in the resident's medical record specifying when the staples were actually removed, who performed the procedure, how many staples were removed, whether any were left, or how the resident tolerated the procedure. Interviews with nursing staff revealed uncertainty about who removed the staples, and the responsible wound care nurse was no longer employed at the facility. The resident's responsible party reported witnessing the staple removal by a male nurse, but this was not reflected in the clinical documentation. The facility's policy required that all assessments, observations, and services provided be documented in a timely and complete manner, including details of procedures such as staple removal. The lack of documentation for this procedure meant the resident's clinical record was incomplete and did not meet accepted professional standards, as required by facility policy and regulatory expectations.