Inaccurate Wound Care Documentation for Thigh MASD
Penalty
Summary
The deficiency involves the facility’s failure to ensure the accuracy of a resident’s medical record regarding wound care. The resident, admitted with multiple sclerosis, paraplegia, an indwelling urinary catheter, frequent bowel incontinence, and moisture associated skin damage (MASD), had a physician’s order dated 3/15/26 for daily wound care to a right thigh wound between 2:00 PM and 10:00 PM. The wound note on 3/16/26 documented a pink right thigh wound measuring 1 cm by 3 cm. On 3/20/26 at 12:02 PM, during incontinence care following an episode of loose stool incontinence that required a complete linen change, surveyors observed a dressing on the back of the resident’s thigh dated 3/16/26, indicating that the dressing had not been changed since that date. A CNA confirmed the dressing date of 3/16/26. Review of the Treatment Administration Record (TAR) showed that the resident’s wound care was documented as completed on 3/17/26 and 3/19/26 by an LPN, and as refused on 3/18/26. The facility was unable to reach the LPN to clarify the documentation. The ADON, who served as the wound nurse, stated that the resident had MASD requiring daily wound care and later reported that the resident refused wound care when requested on 3/20/26. The DON stated that any wound care refusals should be documented in the Progress Notes or TAR and acknowledged that the TAR showed wound care as completed on 3/17/26 and 3/19/26, suggesting the LPN might have incorrectly documented completion or failed to document refusals. The resident’s medical record did not indicate that wound care was refused on 3/16/26 or 3/19/26, resulting in inaccurate medical record documentation related to wound treatment.
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