Incomplete and Inaccurate EMR Documentation for Wound Care and Change in Condition
Penalty
Summary
The deficiency involves failure to maintain complete and accurate electronic medical records and treatment documentation for two residents. One resident with multiple chronic conditions, including dementia, peripheral vascular disease, and a left below-knee amputation, was admitted with moderate cognitive impairment. A progress note documented two skin tears on the left upper arm, and a physician order was obtained for wound care with dressing changes scheduled three times weekly and as needed. The Treatment Administration Record (TAR) showed that LPNs documented that the ordered treatments were provided on specific dates; however, observations on a later date revealed the dressing on the resident’s left upper arm was still dated from the day of injury and was heavily soiled with dried blood. In an interview, one LPN confirmed the dressing had not been changed on the dates documented, verifying that the TAR entries were inaccurate. For the second resident, who had severe cognitive impairment and multiple diagnoses including a right femur fracture, dementia, anemia, and adult failure to thrive, the medical record lacked documentation of an assessment and vital signs at the time of a change in condition. A progress note by an LPN stated the resident was drowsy, would not fully wake up, and was tachycardic, and that the family requested transfer to the hospital, with an order obtained from the CNP to send the resident out. However, the record contained no evidence that the LPN obtained an assessment or vital signs prior to transfer. Another nurse reported that she, not the assigned LPN, initially obtained vital signs showing an irregular pulse in the 120s–130s before the LPN took over. In a subsequent interview, the LPN acknowledged that she had assessed the resident and obtained vital signs earlier but had not documented any assessment or vital signs in the EMR, stating she must have forgotten. The DON confirmed the absence of assessment and vital sign documentation in the medical record and that the change in condition was not identified timely.
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.