Inaccurate Documentation of Pressure Ulcer Location and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record for a resident with a pressure ulcer. Weekly wound assessments dated 11/03/25, 11/11/25, 11/18/25, 11/25/25, and 12/02/25 documented multiple wounds, including a pressure ulcer to the right buttock, but contained no documentation of a wound to the left buttock. These assessments were completed by Nurse #3. Review of the December Treatment Administration Record (TAR) showed physician orders and documented treatments for a right buttock wound over multiple date ranges in December, with Nurse #3 signing off on those treatments on several days. There was no documentation of any wound treatment to the left buttock in the TAR. On observation on 12/17/25 at 8:46 a.m., Nurse #3 was seen providing wound treatment to the resident’s left buttock, and no wound was observed on the right buttock. In a subsequent interview, Nurse #3 acknowledged that since the resident’s admission he had incorrectly documented the wound location as the right buttock instead of the left buttock on both the weekly wound assessments and the treatment orders, and that he had continued to sign off treatments for a right buttock wound after actually treating the left buttock. The DON confirmed that Nurse #3 had informed her that the wound documentation and orders were incorrect and stated that she had not conducted rounds with Nurse #3 and that a process needed to be put in place.
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