Incomplete and Inaccurate Medical Record Documentation for Wound Care
Penalty
Summary
The facility failed to ensure that residents' medical records were complete and accurate, specifically regarding the documentation of wound care and the identification of pressure ulcers. For one resident, review of the treatment administration record (TAR) revealed that a nurse did not document completion of required tracheostomy and PEG tube site care on several night shifts. The nurse later confirmed that the treatments were performed but had not been documented in the electronic TAR, leaving several entries blank for those dates. The Director of Nursing verified that the nurse was responsible for the missing documentation and acknowledged that the medical record was incomplete until the nurse retroactively initialed the TAR. Another resident's medical record contained conflicting and inaccurate information regarding the type, location, and origin date of skin impairments, including a Stage II pressure ulcer and moisture-associated skin dermatitis (MASD). The care plans for this resident contradicted each other, with one indicating a Stage II ulcer and MASD on the left buttock and the other indicating these conditions on the right buttock. Additionally, a wound assessment incorrectly stated that the pressure ulcer was present on admission and listed an incorrect origin date. Progress notes from the wound nurse practitioner also misidentified the locations of the wounds, which was later clarified through an addendum after the discrepancies were discovered. Interviews with facility staff, including the wound nurse and the DON, confirmed that the medical records did not accurately reflect the residents' wound status, locations, and dates of origin. Staff acknowledged ongoing issues with proper documentation and data entry in the electronic medical record system, leading to incomplete and conflicting information in the residents' records.