Failure to Maintain Timely and Accurate Wound Documentation
Penalty
Summary
The facility failed to maintain accurate and timely wound monitoring records for a resident with a Stage 4 pressure ulcer. The resident was admitted with a significant wound over the sacrum, with exposed bone and specific measurements documented at admission. Although the facility had a process in place for weekly wound documentation using a Wound Observation Tool, records showed that several weeks of wound assessments were not entered into the electronic medical record on a weekly basis as required. Instead, multiple weeks of documentation were entered retrospectively, well after the assessments should have been completed. During interviews, the Director of Nursing Services (DNS) acknowledged that the weekly wound documentation was not completed as scheduled and admitted to being behind in documentation. When asked to provide the original source data for the wound documentation, the DNS was unable to produce records consistent with what was entered into the electronic medical record. This lapse resulted in incomplete and potentially inaccurate clinical information being available to the interdisciplinary team.