Incomplete and Inaccurate Medical Record Documentation for Change in Condition and Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident experiencing a change in condition and for wound documentation. The resident was transferred to the hospital for altered mental status. On the date of transfer, Nurse #2 completed a transfer form and an SBAR form that were dated for that day but contained vital signs from the previous day. The SBAR form also had a designated area for additional nursing notes about the change in condition, which was left blank. Review of the medical record showed no narrative progress note documenting vital signs at the time the altered mental status was first observed. In interview, Nurse #2 stated she and the facility Wound Nurse noticed the resident was not responding at baseline, that she took the resident’s blood pressure and pulse, and that the resident was not having labored breathing, but she did not remember the vital sign values and did not enter them into the record, stating she had written them on a piece of paper that was later lost. The DON confirmed that the vital signs taken at the time of the altered mental status were not entered into the electronic medical record, leaving the record incomplete. The deficiency also includes inaccurate wound documentation for the same resident. On an admission skin observation assessment form, the facility Wound Nurse documented an open area on the right buttock. Later, on a skin assessment form, the Wound Nurse documented that the resident was seen by the Wound NP for a pressure sore to the right buttock, and the Wound NP documented a Stage II pressure sore to the right buttock. In a subsequent interview, the facility Wound Nurse confirmed that she had not documented the correct location of the open area on the initial skin observation assessment and that both she and the Wound NP had inaccurately documented the wound as being on the right buttock for several weeks when it was actually on the left buttock. The DON, present during the interview, stated that both the Wound Nurse and the Wound NP were newer to their roles, which may have contributed to the inaccurate documentation.
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