Failure to Maintain Weekly Wound Documentation in Medical Record
Penalty
Summary
The facility failed to maintain accurate and thorough wound documentation in the medical record for Resident #2, who was admitted with diagnoses including quadriplegia, muscle weakness, contractures, and abnormal posture. The resident’s care plan identified Stage 4 pressure ulcers on the left ischium and right buttock, with interventions such as scheduling wound clinic appointments and providing treatment as ordered, but did not include interventions for at least weekly wound assessments or documentation. Review of the medical record showed weekly wound assessments documented on 12/03/25, 12/10/25, 12/18/25, 12/26/25, and 01/14/26, but there was no documentation of weekly wound assessments between 12/26/25 and 01/14/26 (18 days) and between 01/14/26 and 02/03/26 (19 days), despite the resident having ongoing Stage 4 pressure ulcers confirmed by an outside wound nurse practitioner and an after-visit summary. The resident, who had intact cognition but was totally dependent on staff for ADLs including turning, transfers, toileting, hygiene, and showers, continued to have two Stage 4 pressure ulcers not present on admission. Observation of wound care confirmed the presence of these Stage 4 ulcers. The LPN responsible for following the wounds acknowledged that weekly wound assessments were required and confirmed that no wound assessments were entered into the resident’s medical record during the identified gaps. She reported difficulty completing all wound responsibilities after the former ADON left and stated she was unable to get to all measurements. She later produced weekly wound tracking logs, submitted to corporate, that contained weekly measurements and assessments for multiple residents, including this resident, but verified that these logs were not part of the resident’s medical record and that she had not documented the weekly wound assessments into the record, contrary to the facility’s wound documentation policy requiring assessments every seven days with specific elements recorded.
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