Incomplete and Inaccurate Medical Record for Resident Catheter Care and Skin Status
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with multiple diagnoses, including a non-displaced left wrist fracture, depression, bipolar disorder, malignant melanoma of the trunk, and congestive heart failure. An admission nursing assessment documented that the resident was alert but confused and indicated that catheter care was to be provided by nursing assistants. The nursing assistant task bar showed catheter care scheduled every shift from late December through late January, but there was no documentation that this care was completed except for three day shifts in January. The urinary catheter was discontinued on 01/22/25. The DON stated there was no catheter care documentation in December because the task did not appear on the aide task bar until the baseline care plan evaluation was completed and acknowledged that only three days in January showed completion, characterizing the issue as a documentation problem rather than a failure to provide care. The resident’s admission assessment and a wound nurse practitioner note shortly after admission both documented intact skin with no open wounds. However, multiple skilled evaluations later documented skin concerns and dressings as dry and intact on several dates in January, yet no corresponding skin or wound assessments could be located in the medical record. During interviews, an RN and a CNA both denied that the resident had any wounds or dressing changes, stating they were only aware of a wrist cast. The DON also reported that the resident’s skin remained intact throughout the stay and stated that the skilled evaluations indicating skin concerns and dressings were incorrect. These inconsistencies between clinical documentation, staff interviews, and the absence of wound assessments demonstrated that the resident’s medical record was not complete or accurate.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.