Incomplete and Inaccurate Medical Record Documentation for Wound Care and Change in Condition
Penalty
Summary
The deficiency involves failures to maintain complete and accurate medical records for two residents. For one resident with a midline abdominal surgical wound, the Treatment Administration Record (TAR) for a specified period showed that surgical wound care was documented as completed every shift per physician orders. However, a nursing progress note later documented that on one date the dressing was changed and the old dressing was still dated several days earlier, indicating that wound care had not been performed as ordered during that interval. The same note described increased drainage with thick brown serosanguineous fluid and increased redness around the surgical site, and the wound nurse was notified of the worsening appearance. A communication form entry further documented that the abdominal incision was reddened with purulent drainage, that the resident reported the dressing had not been changed for several days, and that a wound culture was positive for gram negative and gram positive bacteria, confirming an infected surgical wound. The DON stated that it was her expectation that wound care be accurately documented and performed according to physician orders and confirmed that the TAR documentation showing wound care as completed on the specified dates was not accurate. For another resident who experienced a change in condition, the Electronic Health Record (EHR) did not contain documentation of vital signs taken in the early morning following that change. Record review showed that vital signs obtained at a specific time were not entered into the EHR after the change in condition occurred. In an interview, the DON confirmed that the resident’s vital signs were not documented in the EHR after the change in condition and acknowledged that they should have been documented. These findings show that the facility failed to ensure that medical records, including treatment documentation and vital signs following a change in condition, were complete and accurate for both residents.
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