Repeat Deficiencies in Wound Care Management and Clinical Record Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective quality assurance and performance improvement (QAPI/QAA) oversight of wound care and clinical record accuracy, resulting in repeat deficiencies. During a prior recertification survey, deficiencies were cited for quality of care related to wound care for two of three residents reviewed, and for incomplete and inaccurate clinical records for two of three residents reviewed for wound care. Despite having a written plan and a stated completion date, the facility’s quality assurance committee did not ensure that these issues were effectively corrected, as the same areas of noncompliance were identified again during a subsequent complaint survey. During the complaint survey, a resident was found to have had a pressure ulcer upon admission, with no physician orders for care and treatment of the wound documented in the clinical record, demonstrating a continued failure in quality of care for pressure ulcers. In addition, another resident’s clinical record lacked complete and accurate information related to wound care, showing that the facility did not maintain accurate, identifiable clinical records as previously cited. At the exit interview, the Administrator and DNS acknowledged that the facility’s prior plan of correction for these areas had not been effective, and that deficient practices persisted beyond the anticipated date of compliance.
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