Failure to Accurately Document and Notify Health Care Agent of Pressure Injuries
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple diagnoses, including vascular dementia, diabetes mellitus, depression, and anxiety. On review, documentation in both the Nurse Progress Note and the Skin Incident Report indicated that the resident's Health Care Agent (HCA) and provider were notified of newly observed deep tissue injuries to the resident's heels. However, interviews with the nurse responsible for the documentation revealed that only the provider was notified, and the nurse had not contacted the HCA as documented. The nurse stated she believed the Unit Manager had made the notification, but the Unit Manager did not recall doing so. Further interviews with the Unit Manager and the Director of Nursing (DON) confirmed that the expectation was for nursing staff to promptly notify the HCA of any significant change and only document such notification once it had occurred. The DON assumed proper notification had been made based on the documentation, but it was determined that the HCA had not actually been notified as required. This discrepancy between documentation and actual practice resulted in incomplete and inaccurate medical records for the resident.