Failure to Maintain Consistent Documentation for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to maintain current, detailed, and consistent medical records for one resident who required turning and repositioning every two hours to prevent the worsening of a stage four pressure ulcer, as ordered by the physician. The facility's policy required documentation of the date and time care was given, the names and titles of staff involved, the position in which the resident was placed, reasons for changing position, resident participation, any problems or complaints, refusals and interventions, and the signature and title of the person recording the data. However, a review of the resident's records revealed multiple gaps in documentation by both CNAs and nurses over several days, with missing entries for required time slots and shifts. The resident involved had severe cognitive impairment, a history of a stage four pressure ulcer, Type 2 Diabetes Mellitus, and tracheostomy status, and was unable to make decisions or understand care instructions. Despite physician orders and facility policy, staff failed to consistently document turning and repositioning in both the bedside folder and the computer system. During an interview, the RNS confirmed that if documentation was missing, it indicated the resident was not turned or repositioned as required. These documentation lapses were observed over a period of several days, affecting the resident's prescribed wound care regimen.