California Nursing Home Administrator License Practice Exam

Which of the following records must document resident information related to a stage 2 pressure sore?

1. Admission and discharge log

2. Medication observation record

3. Resident care plan

4. Incident report

The correct answer is: Admission and discharge log

The correct choice is the resident care plan. This document is essential in nursing home settings as it outlines the comprehensive approach to an individual resident's care, including specific medical conditions, treatment plans, and interventions. When a resident has a stage 2 pressure sore, the care plan must reflect this condition, detailing the strategies for prevention, treatment, and monitoring of the sore, as well as the involvement of various healthcare professionals in the resident's care. The care plan ensures that all staff members are informed about the resident's needs and the necessary actions to address them. By documenting the presence of the pressure sore and its stage, the plan not only prescribes appropriate interventions but also establishes goals for healing and prevents further skin breakdown. The admission and discharge log typically records the details of residents entering and leaving the facility rather than ongoing care specifics. A medication observation record mainly focuses on the administration and monitoring of medications without detailing specific resident care needs like pressure sores. An incident report addresses specific events or occurrences that could result in injury or harm but does not provide ongoing treatment information or care planning related to chronic conditions like pressure sores. Therefore, these documents do not serve the purpose of comprehensively managing and documenting the treatment of stage 2 pressure sores.