Inaccurate Documentation of Wound Location in Resident Medical Record
Penalty
Summary
The facility failed to ensure accurate clinical records for a resident with a surgical wound. Specifically, documentation inconsistently recorded the location of the wound, with multiple entries indicating the wound was on the right plantar foot when it was actually on the left. This error originated from the initial wound note, where the wound nurse mistakenly charted the right foot instead of the left, and this incorrect information was subsequently carried over in ongoing documentation. Weekly skin observations and progress notes continued to reflect the incorrect wound location, and some weekly observations even failed to note the presence of a surgical wound. The resident involved had a complex medical history, including a displaced bimalleolar fracture of the left lower leg, diabetes, hemiplegia, lymphedema, morbid obesity, and chronic heart failure. The care plan and physician orders correctly referenced a surgical wound on the left foot, but nursing documentation and skin observation forms repeatedly listed the wound as being on the right foot. Interviews with staff confirmed that documentation was based on previous notes rather than direct observation, leading to persistent inaccuracies in the resident's clinical record.