Failure to Maintain Complete and Accurate Treatment and Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, as required by its own charting and documentation policy. For one resident with muscle weakness and a need for assistance with personal care, the January 2026 Treatment Administration Record (TAR) showed missing documentation for several ordered treatments. These included wound care to a ruptured blister on the left inner knee with no documentation on one date, wound care for a right forearm skin tear with missing entries on two dates, use of bilateral pressure-relieving boots with no entry on one date, catheter care with no entry on one date, G-tube placement checks with no entry on one date, and coccyx wound care with missing documentation on five separate dates. The TAR did not indicate whether these treatments were completed or refused on the listed dates. Another resident with type 2 diabetes mellitus and pneumonia had incomplete documentation on the February 2026 TAR. There was no recorded entry for a morning pulse oximetry assessment on one date, despite an order related to pneumonia. Wound care orders for a right medial gluteal community-acquired stage 3 (now unstageable) pressure injury, requiring cleansing with normal saline, application of hydrogel, and border gauze every shift, lacked documentation on three dates. Additionally, ordered betadine application to a community-acquired unstageable deep tissue injury (DTI) on the left heel was not documented on two dates, and required checks of the oxygen concentrator for proper function and flow rate every shift were not documented on one date. The TAR did not show whether these treatments and checks were completed or refused. A third resident with repeated falls, multiple sclerosis, dementia, anxiety, and weakness had no weekly skin assessments documented for multiple specified weeks in November and December 2025. Interviews with nursing staff indicated that weekly skin assessments were expected to be completed to identify changes in skin condition, and that these assessments appeared in the electronic record as UADs (assessments) to be completed by nurses. Staff reported that UADs could be skipped and reassigned, and that if not completed within 24 hours they would disappear from the alert system. The DON stated that unit managers were supposed to review shower sheets and resident care tasks daily and follow up on missed documentation or care, and that nurses were expected to document any missed treatment with an explanation in a progress note, but such documentation was not present for the missed treatments and assessments identified.
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