Inaccurate Documentation of Venous Ulcer Location in Clinical Record
Penalty
Summary
The facility failed to ensure that a resident's clinical record contained accurate and complete information regarding the location of a venous ulcer over a seven-month period. Documentation provided to the surveyor indicated that the resident had a chronic ulcer being treated on the right lower extremity, and physician progress notes consistently referenced treatment for right lower leg wounds. However, a progress note written by a registered nurse on 10/3/25 incorrectly documented treatment on the left lower leg and noted a new abrasion on that leg. The care plan also inaccurately identified the left lower leg as the site of the venous wound, despite ongoing treatment and documentation indicating the wound was on the right lower leg. Further review of the care plan revealed that the focus on the left lower leg had been in place since 10/2/24 and was revised multiple times, but continued to reference the incorrect extremity. The goals and interventions under this focus were also updated without correcting the error. During the record review, the registered nurse confirmed that the resident had never had a venous wound on the left leg and acknowledged the documentation error in both the care plan and the progress note. The surveyor verified that the clinical record and care plan did not accurately reflect the correct location of the venous wound.