Inaccurate Documentation of Compression Stocking Use for Edematous Legs
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident with multiple chronic conditions, including COPD, hypertensive heart disease, type 2 diabetes, heart failure, and arthritis. The resident was admitted in late October and had a quarterly MDS showing dependence on staff for several ADLs. In early December, weekly skin checks and a health status note documented bilateral lower extremity edema, hardness, cracking, seeping clear liquid, and scant clear drainage. In response, a physician order dated 12/10/25 directed that compression stockings be applied in the morning and removed at bedtime daily and on night shift for leg edema. However, review of the Treatment Administration Record showed that staff documented the compression hose as being on for multiple days in January and the first days of February, despite the resident not being provided compression stockings during her stay. On the day of surveyor interviews and observations in February, the resident was observed without compression stockings, with edematous, red lower legs and thin scabs on the left lower shin, and reported itching and scratching. The resident stated she had never worn compression hose at the facility, no one had asked her about wearing them, and that at her previous facility her legs had been wrapped for edema. A CNA reported the resident was retaining a lot of fluid in her legs, had never seen the resident with compression stockings, noted there were none in the room, and that application of stockings did not appear in their electronic charting. Despite this, the Treatment Record for that day was signed off indicating the resident had compression stockings on. An RN confirmed she had signed the treatment sheet indicating the resident had compression stockings on when the resident did not, demonstrating inaccurate documentation in the medical record.
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