Incomplete and Inaccurate Wound Care Documentation for Heel Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and treatment documentation for a resident with a right heel pressure injury. The resident was admitted with weakness and falls and had an active care plan for a right heel pressure injury requiring wound care per physician orders and weekly skin evaluations. Review of physician orders and treatment records from December through February showed multiple missed and refused wound care treatments without corresponding progress notes or documentation of PRN wound care, despite orders specifying every other day, then daily wound care, and checks of dressing placement. The care plan also called for weekly full skin checks, but several of these were not completed on specified dates. The Unit Manager stated she was aware of issues in December and January with wound dressings not being changed and incomplete documentation, and confirmed that refusals of wound care in February were not supported by progress notes or documentation of re-attempts. The Nurse Practitioner reported that on two separate visits, the resident’s right heel dressing was grossly soiled, had not been changed for several days beyond the ordered frequency, and did not match the ordered dressing type on one occasion. The NP documented concern for cellulitis, ordered oral antibiotics, and later added a topical antibiotic and daily dressing changes when the wound deteriorated, but on a subsequent visit again found a soiled dressing that had not been changed as ordered and noted the topical antibiotic was not available. Medication records showed the resident did not receive all ordered doses of oral antibiotics in both December and January. Additionally, a Treatment Administration Record entry showed that an LPN documented checking the placement of the right heel dressing, but in interview that LPN stated she was not aware of a wound dressing on the resident, despite having documented the check that same morning. The ADON acknowledged finding the resident’s dressing not changed, missing documentation, and documentation indicating dressings had been changed more than once in the past, and was aware that the wound care provider had previously been upset about dressings not being changed as ordered.
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