Inaccurate Documentation of Surgical Site and Wound Assessment
Penalty
Summary
The facility failed to maintain accurate and consistent documentation for a resident who had undergone left hip hemiarthroplasty. Record reviews revealed discrepancies in the resident's medical records, including conflicting information about the location of the surgical site, the presence of hematuria, and the timing and identification of wound dehiscence. For example, the Inter-Facility Transfer Report and admission records indicated a left hip surgical site, but a Daily Body Check incorrectly documented treatment on the right hip. Additionally, a nurse misinterpreted 'hematuria' as bloody discharge from the surgical site, when it actually refers to blood in the urine, leading to inaccurate wound assessment documentation. Further inconsistencies were found in the documentation of the resident's change of condition, with the timing of wound dehiscence being incorrectly recorded as occurring in the morning instead of the afternoon. Interviews with the Treatment Nurse and Director of Nursing confirmed these documentation errors. The facility's policy requires nursing documentation to be accurate and based on the resident's condition, but these standards were not met in this case.