Incomplete and Inaccurate Medical Record Documentation for Wound Care
Penalty
Summary
Staff failed to ensure that medical records were complete and accurate for a resident who was admitted with a left fibula fracture and had an order for suture and staple removal from the left leg. The physician's order specified that the sutures and staples should be removed, and staff documented in the Treatment Administration Record that this procedure was completed as ordered. However, subsequent wound photographs taken several days later showed that both sutures and staples remained in place on the resident's leg. Further review of wound clinic documentation revealed that the sutures and staples were not actually removed until a later visit to an outside wound care clinic. During an interview, the Director of Nursing confirmed that staff had documented the removal of sutures and staples even though the procedure had not been performed. This inaccurate documentation resulted in incomplete and misleading medical records for the resident.