Inaccurate Clinical Documentation for Continence, Tube Feeding, and Wounds
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and consistent clinical documentation for a resident with paraplegia/functional quadriplegia, dementia, and cancer. The resident had a physician order for a suprapubic catheter, but nursing assistant documentation repeatedly recorded the resident as incontinent of urine on multiple dates in December. The MDS assessment also coded the resident as always incontinent of urine. The DON later stated this documentation was incorrect because the resident was not incontinent of urine, and the MDS coordinator confirmed the MDS was coded incorrectly. Additionally, the wound consultant’s note documented urinary incontinence based on an assumption related to bowel incontinence, and the wound consultant stated they were unaware the resident had a suprapubic catheter. Further documentation discrepancies involved PEG tube feeding and wound assessments. Medical provider notes on several dates listed SNF recommendations that included PEG tube feeds, but the physician assistant later stated the resident did not have PEG tube feeds and that these recommendations were erroneously pulled from hospital records using artificial intelligence and not corrected on proofreading. Wound documentation was also inconsistent: the admission evaluation identified a Stage 2 pressure ulcer on the coccyx, a later weekly skin evaluation documented a Stage 2 pressure ulcer on the sacrum, and the wound consultant’s initial assessment described a partial-thickness MASD wound on the left buttock extending across both buttocks. The resident care manager/LPN could not determine from the record whether these were the same wound, and the wound consultant reported being unaware of a coccyx/sacral wound or a healed Stage 4 pressure ulcer on the sacrum, indicating unclear and inaccurate wound documentation in the medical record.
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