Failure to Accurately Document Wound Care and Identify Staff in EMR
Penalty
Summary
The facility failed to ensure that medical records for a resident receiving wound care were accurately documented in accordance with professional standards. Specifically, the Wound Assessment Record (WAR) for one resident did not reflect that wound care to both lower extremities was completed as ordered for multiple days in October. The documentation was incomplete, with several dates missing sign-offs, and there was no way to verify that the care had been provided on those days other than verbal confirmation from nursing staff. Additionally, some entries were made retroactively, and the staff member responsible for certain initials in the electronic medical record (EMR) could not be identified. The resident involved had a history of diabetes, non-pressure chronic ulcers of both lower legs, congestive heart failure, hypertension, and atrial fibrillation. Physician orders required daily wound care, including cleansing, application of Xeroform, ABD pads, and gauze wrapping. The care plan and Minimum Data Set (MDS) confirmed the need for ongoing wound care and indicated the resident was moderately cognitively impaired but able to communicate needs. Despite these requirements, the WAR did not consistently show that wound care was performed as ordered, and staff interviews revealed that documentation was sometimes completed after the fact or not at all. Interviews with the DON and nursing staff confirmed that there was confusion regarding documentation practices, with some nurses documenting in different parts of the EMR or forgetting to sign off on the WAR. The DON was unable to determine the identity of a staff member whose initials appeared in the EMR, and the facility's policy only allowed authorized users with assigned credentials to access and document in the system. The lack of accurate and timely documentation meant that it could not be proven that the resident received the ordered wound care on the specified dates.