Inaccurate Wound Documentation and Skin Assessments for Residents With Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical records and skin assessments for two residents with pressure injuries. One resident was admitted with a stage 2 pressure ulcer to the coccyx, measuring 2.3 x 4.2 cm. The facility’s weekly wound report for this resident later documented a coccyx deep tissue pressure injury and then an unstageable coccyx wound with changing measurements and wound characteristics over several weeks. However, during the weekly skin check dated 09/29/25, staff documented "No" to the question of whether the resident had any skin impairment, despite the ongoing documentation of a coccyx pressure injury in the wound tracking system. The weekly skin check also stated that the assessment was completed using direct observation and communication with the resident and staff, creating a direct inconsistency between the skin check and the wound documentation. For the second resident, the face sheet showed an admission date of 01/29/24, and the care plan initiated on 10/29/24 identified a history of ulcers and risk for pressure ulcer development, but there were no further updates to the care plan related to wounds or treatment interventions as of 11/18/25. The Treatment Administration Record (TAR) contained an order for daily wound care to a stage 2 pressure injury to the coccyx, including cleansing, application of a collagen sheet, and dressing changes. The TAR showed wound care as completed on multiple dates between 11/05/25 and 11/19/25. However, during an observation of wound care on 11/18/25, the DON noted that the date on the resident’s dressing was 11/12/25, indicating the dressing was six days old and that wound care had not been provided since 11/12/25. The DON stated that the documented wound care on the TAR from 11/13/25 through 11/17/25 would therefore be false documentation by the RN.
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