Incomplete and Inaccurate Documentation of Resident Skin Conditions
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple complex medical conditions, including a right femur fracture, several pressure ulcers, MRSA, right lung cancer, post-operative anemia, and osteoporosis. Upon review, the resident's admission MDS assessment documented the presence of surgical wounds and multiple pressure ulcers. However, subsequent Skilled Evaluation assessments completed by nursing staff did not identify or document any skin issues, surgical wounds, or infection control precautions, despite the resident's known conditions. Interviews with nursing staff confirmed that the skilled evaluation forms should have reflected these active skin concerns and infections, but they were not properly documented. Further interviews with the Director of Nursing and the Administrator revealed an expectation that nursing staff accurately identify and code current skin issues and infection control concerns on daily skilled charting. The facility had recently changed assessment forms, which was noted as a possible contributing factor to the documentation errors. The facility's policy requires that medical records be complete and accurately document residents' medical conditions, but this was not followed in this instance, resulting in incomplete and inaccurate records for the resident.