The Nursing and Rehab Center at Stadium Place failed to accurately document when and where Resident 301 developed pressure injuries to both heels, according to federal inspectors who reviewed the case in October.
The resident's family filed a complaint on September 9 with the state agency, expressing concerns about their loved one's wounds and care. What inspectors found revealed a troubling pattern of inaccurate medical records.
According to facility assessments, Resident 301 entered the nursing home with no pressure sores but was considered at risk for developing them. Weekly skin assessments from July 28 through September 1 documented the resident's skin as intact.
Everything changed on September 8. That day's assessment suddenly indicated the presence of unstageable pressure injuries to the right heel and a deep tissue injury to the left heel. The same day, the resident was transferred to the hospital at the family's request.
The wound nurse practitioner, identified as Staff 9, completed a wound assessment note that same day. But instead of documenting the wounds as facility-acquired, she wrote that the wound was "not acquired in house" and listed the acquisition date as July 19 — nearly seven weeks before the injuries were actually first noted.
The Director of Nursing initially told inspectors the wounds were unavoidable because Resident 301 was totally dependent and continued to decline. When asked to clarify when the wounds were acquired, she stated they were acquired in the facility and first noted on September 8.
When confronted with the discrepancy between her statement and the wound documentation, the Director of Nursing said she would inform the wound nurse practitioner about the error.
The surveyor attempted to reach Staff 9 by phone multiple times, leaving a voicemail message. No answer.
Later that day, the Director of Nursing reported she had spoken with Staff 9 about the documentation error. She said the wound nurse practitioner acknowledged incorrectly documenting that the heel wounds were not facility-acquired and had entered the wrong acquisition date of July 19. Staff 9 agreed to write an addendum correcting the documentation.
The next morning, Staff 9 called the surveyor directly. She confirmed that Resident 301 had incontinence-associated dermatitis on the buttocks and pressure injuries to both heels. When informed about the incorrect acquisition documentation, Staff 9 admitted the documentation error was hers and said she had written an addendum correcting the information.
The timing raises questions about the facility's wound care protocols and documentation practices. The resident's skin remained intact through weekly assessments for more than a month, then suddenly developed severe pressure injuries that required hospital transfer.
Pressure injuries, also called bedsores, develop when sustained pressure reduces blood flow to skin and underlying tissue. They're considered a key indicator of nursing home care quality, with many cases preventable through proper positioning, nutrition, and skin care.
The facility's Minimum Data Set assessments — federal forms used to track resident conditions — showed the progression clearly. The resident entered with no pressure sores but at risk, used pressure-reducing devices, then developed unhealed pressure injuries classified as unstageable and deep tissue injuries.
Deep tissue injuries appear as purple or maroon areas of intact skin and indicate damage to underlying soft tissue from pressure or shear. They can rapidly deteriorate and expose additional tissue layers.
The wound nurse practitioner's initial documentation suggested the injuries predated the resident's stay by nearly two months. But facility records showed continuous intact skin assessments until the day the wounds were first noted.
Staff 9's false documentation could have significant implications for the facility's quality ratings, Medicare reimbursement, and legal liability. Nursing homes face financial penalties and regulatory sanctions for facility-acquired pressure injuries.
The Director of Nursing acknowledged the documentation accuracy concerns and promised a facility-wide audit. She told inspectors she would review all residents with wounds to verify accurate wound acquisition documentation and prevent future errors.
But the damage to Resident 301 and the family's trust was already done. The resident developed severe pressure injuries that required hospitalization, while staff initially tried to document the wounds as someone else's problem.
The family's complaint ultimately exposed the false documentation, but only after their loved one suffered preventable harm and was rushed to the hospital with wounds the facility claimed weren't their responsibility.
Full Inspection Report
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