Inaccurate Documentation of Skin Impairments in Medical Records
Penalty
Summary
The facility failed to ensure that medical records accurately documented skin impairments for a resident with multiple complex medical diagnoses, including chronic obstructive pulmonary disease, heart failure, atrial fibrillation, and generalized muscle weakness. The resident had several skin conditions, such as arterial ulcers and skin tears, which required specific wound care treatments as ordered by providers. However, a review of the clinical record, Minimum Data Set (MDS), and wound evaluations revealed inconsistencies and omissions in the documentation of these skin impairments, particularly in the discharge summary and instructions provided to the resident's representative. During the resident's stay, multiple provider orders directed staff to perform specific wound care interventions for various wounds on the resident's toes and knee. Despite these orders and ongoing wound care, the discharge summary and transition of care documents did not accurately reflect the resident's current skin conditions at the time of discharge. The resident's representative reported receiving written discharge instructions that did not match the actual status of the wounds, leading to concerns about insufficient communication and incomplete documentation regarding the resident's wound care needs. Interviews with facility staff, including CNAs, RNs, and the DON, confirmed that documentation practices relied on multiple staff members completing different sections of the electronic record, sometimes without re-verifying previously entered information. This process contributed to the omission of critical wound care information in the discharge summary. The facility's own investigation acknowledged that incorrect documentation was submitted on the discharge assessment, and staff interviews highlighted the importance of accurate recordkeeping for continuity of care.