Inaccurate Documentation of Pressure Ulcer Assessment and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and complete medical record documentation for a resident with multiple comorbidities, including type 2 diabetes mellitus, chronic kidney disease, and left hemiplegia, who was admitted with a Stage II pressure ulcer on the coccyx. The Weekly Pressure Ulcer Injury Record dated 11/3/25 documented a Stage II coccyx pressure ulcer measuring 1 x 0.3 cm. The Treatment Administration Record for November 2025 showed physician orders for coccyx pressure ulcer care and moisture-associated skin damage care every shift and as needed. However, the TAR indicated that one LVN signed off only seven of 20 scheduled night-shift treatments for this resident. During a telephone interview and concurrent record review, the LVN who completed the weekly assessment dated 11/12/25 stated he did not perform treatments on the night shift and acknowledged that when he assessed the coccyx pressure ulcer, he only took a quick, superficial look and did not measure the wound. In another interview and review of the weekly assessment dated 11/19/25, a second LVN stated she documented the presence of a Stage II coccyx pressure ulcer but did not measure it because she believed it had already healed, and she left the notation as a reminder that a pressure ulcer had previously been present. The facility’s policy on Weekly Nurses Progress Notes states that these notes are part of the medical record and must summarize the resident’s condition based on the nurse’s assessment and reflect the assessment at the time of documentation, which was not followed in these instances.
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