Failure to Maintain Accurate Medical Records for Wound Care, Nutrition, and Code Status
Penalty
Summary
The facility failed to maintain accurate and consistent medical records for three residents regarding wound care, nutritional intake, and code status documentation. For one resident with heart failure, muscle weakness, and dysphagia, there was a discrepancy between the physician's order in the electronic medical record, which indicated Full Code status, and the POLST form signed by the social worker, which indicated Do Not Resuscitate (DNR). The Director of Nursing confirmed that the POLST form did not accurately reflect the physician's order in the electronic system. Another resident with dementia had a physician's order for daily wound care to bilateral hallux ingrown toenails. Documentation showed the treatment was marked as completed daily, but an investigation revealed the dressing had not been changed as ordered, with the last actual change occurring several days prior. Additionally, a resident with chronic kidney disease and dementia experienced significant weight loss, and staff observations indicated poor nutritional intake. However, the resident's intake was inaccurately documented as 75-100% consumed, despite staff interviews and direct observation showing much lower intake.