F0842

D

Incomplete and Inaccurate Wound and Skin Documentation for a Resident

Ligonier, Indiana Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records that reflected a resident’s clinical status, particularly related to skin integrity and wound care. The resident had multiple serious diagnoses, including end-stage kidney disease on dialysis, a stage 4 sacral pressure ulcer, and a history of multiple cancers, and was alert and able to make his own decisions. A care plan noted a suspicious lesion on the left lower extremity that was later diagnosed as benign and treated with chemotherapy cream, with interventions to assess and document the skin condition weekly and as needed. A dermatology visit documented a Dermablade biopsy of a non-healing lesion on the left lower extremity with instructions for local wound care, and reference material indicated such biopsy sites typically heal in 7–10 days. However, there was no documentation in the facility record that the biopsy site remained open, was monitored, or was treated after the procedure, nor any indication that a new biopsy had been performed.

Subsequent documentation showed multiple inconsistencies and omissions regarding new and existing wounds and bruising. A nurse note and New Skin Event form documented a new open wound on the left inner ankle with drainage, but the form lacked depth and full wound assessment details. An IDT note linked this wound to a prior biopsy and described its appearance and drainage, but there was no further assessment or investigation recorded. Wound management reports later provided by the wound nurse contained measurements but did not specify the cause or type of wound, peri-wound assessment, or wound-specific interventions. A NP note described a new open wound on the left outer lateral lower leg, which the resident believed was being managed by a wound clinic, yet the facility record did not reflect a separate lateral wound or clarify that there were two distinct wounds on the left lower leg. Additionally, a NP note documented bruising to the left back, left lateral abdomen, and right forearm, but these findings were not recorded on the facility’s skin, wound sheets, or progress notes.

Further gaps in documentation included a cancelled wound clinic appointment with no record of rescheduling or weekly wound measurements, and incomplete information regarding skin tears and bruising. A nurse note reported two skin tears on the right hip without documenting their size, physician notification, or treatment. An IDT note the next day described a diffuse purple bruise on the right hip and stated there were no skin tears or swelling, but did not document assessment, measurement, monitoring, or cause of the bruising. Another nurse note referenced ongoing skin tears without specifying their location. Interviews with nursing staff and leadership confirmed that facility policy required new skin impairments to be fully documented on New Skin Event forms, with measurements, assessments, treatments, and notifications, and that the wound nurse was responsible for weekly wound monitoring and complete documentation. Despite this, the resident’s record lacked thorough, timely, and complete entries consistent with the facility’s Skin Management Program policy.