Failure to Document Hospital Transfer and Provider Order for Wound Evaluation
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident who was at risk for pressure ulcers and had an existing unstageable heel pressure ulcer/deep tissue injury. The resident, an older female with peripheral vascular disease and bed confinement status, had a care plan identifying a pressure ulcer to the heel and interventions including immediate nurse notification of any new skin breakdown. On the referenced date, an LVN (LVN B) performed wound care, assessed the resident’s heel, and noted that it was purple but not open. LVN B contacted the nurse practitioner, who gave a new order to send the resident to the emergency room for further evaluation of the right heel wound, and LVN B then informed the charge nurse (LVN A) of this new order. According to interviews, LVN A stated that she called the emergency room to give report and that the resident was transferred via ambulance for evaluation of the right heel wound. However, LVN A acknowledged that she did not document in the resident’s medical record that the resident was transferred to the emergency room, stating she became busy with other residents and forgot to document the transfer and the physician’s order before the end of her shift, despite knowing documentation should have been completed. LVN B stated she did not document the change in condition because she was not the resident’s nurse and had informed LVN A, the charge nurse. The DON stated that the facility’s expectation is that documentation of changes in condition be timely, accurate, and completed in real time or before the end of the shift. Review of the facility’s documentation policy confirmed that cares provided are to be recorded in the electronic record each shift, but the resident’s record lacked documentation of the hospital transfer and the associated order for evaluation of the right heel wound.
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