Inaccurate Wound Documentation and Incomplete ADL Charting
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a dependent resident with multiple pressure injuries. The facility’s charting and documentation policy required that services provided, progress toward care plan goals, and any changes in a resident’s condition be documented in the medical record, and that objective observations and treatments be recorded. The resident, admitted with multiple diagnoses including dementia, depression, muscle wasting, anxiety, and dysphagia, had a care plan and MDS indicating dependence on staff for most ADLs, including transfers, bathing, dressing, and personal hygiene. Despite this, nursing documentation in progress notes and at least one weekly skin evaluation repeatedly indicated that the resident’s skin was intact and that there were no pressure injuries over multiple dates in October, November, and December. A weekly skin evaluation on 11/14 also documented clean, intact skin. These entries conflicted with the resident’s pressure ulcer evaluations, which consistently documented a Stage 3 pressure injury to the sacrum on multiple dates, as well as additional Stage 2 and Stage 3 pressure injuries on the right sacrum, left sacrum, and left buttock. During interviews, the SDC and DON acknowledged ongoing issues with nurses documenting skin as intact when residents had open areas or pressure injuries, and a nurse who authored many of the notes admitted she had inaccurately documented the resident’s skin as intact and without pressure injuries. The facility also failed to ensure complete CNA documentation of ADLs for this resident. Review of CNA ADL flow sheets for October and November showed multiple days and shifts where all ADL care areas were left blank, including several day, evening, and night shifts each month. CNAs reported that ADL documentation is done in Point of Care in the EMR and must be completed by the end of each shift, and the DON stated that CNA documentation should not be incomplete and that all care provided should be documented by the end of every shift. Nonetheless, the records showed repeated omissions, resulting in incomplete daily documentation of the resident’s ADL care.
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