Failure to Accurately Document Wound Assessments in Medical Records
Penalty
Summary
The facility failed to maintain accurately documented medical records for two of three residents reviewed, specifically regarding wound assessments. For both residents, the facility did not ensure that wound assessments included required details such as measurements, wound progression, and treatment effectiveness. The documentation only noted the location of the wounds without providing comprehensive assessment data, which is contrary to the facility's own policy that requires detailed wound care documentation, including wound bed color, size, drainage, and any changes in condition. One resident, who had diagnoses including pulmonary embolism, type 2 diabetes, and muscle weakness, had multiple wound care orders for the lower extremities. However, the skin/wound notes for this resident lacked detailed assessments and did not include measurements or descriptions of wound progression. Similarly, another resident with cellulitis, sepsis, and mobility difficulties had wound care orders for the left leg, heel, and foot, but the documentation again failed to provide detailed wound assessments, only noting the wound's location. Interviews with staff, including an LPN certified in wound care and the DON, confirmed that wound assessments should include measurements and detailed descriptions, and that such documentation was lacking. The DON acknowledged the deficiency and noted that accurate wound documentation is necessary for evaluating treatment effectiveness. The facility's medical director also stated that he relied on nursing staff for wound assessment details and was unaware that the required documentation was not being completed.