Failure to Maintain Complete and Accurate Medical Records for Wound and Orthopedic Care
Penalty
Summary
A deficiency was identified when the facility failed to maintain a complete and accurate medical record for a resident who developed an open area on the coccyx and had a left clavicle fracture. The facility's policies required documentation of services provided, progress toward care plan goals, and any changes in the resident's condition, as well as detailed wound assessments and treatment documentation. However, for the resident in question, there was no nursing documentation regarding the characteristics or progress of the coccyx wound, nor was there evidence that a pressure form was implemented as required by facility policy. Additionally, the resident returned from the hospital with a discharge summary recommending the use of a sling for the left arm, daily monitoring of the skin around the sling, and maintaining non-weight bearing status until further orthopedic evaluation. Despite these recommendations, there was no documentation in the medical record, physician orders, Treatment Administration Record, or Nurse Progress Notes to support that the resident's left arm was placed in a sling, monitored by nursing staff, or that non-weight bearing status was maintained. Interviews with nursing staff and the DON confirmed that these actions were expected but not documented or, in some cases, not performed. The lack of documentation and follow-through on both wound care and orthopedic management represented a failure to adhere to the facility's own policies and accepted professional standards for medical recordkeeping. This deficiency was substantiated through record review and staff interviews, which revealed gaps in both assessment and documentation for the resident's identified medical needs.