Inaccurate Pressure Ulcer Assessment on Admission
Penalty
Summary
The facility failed to comprehensively assess and document a pressure ulcer for a resident, identified as Resident R42, upon admission. The facility's policy requires that pressure injuries be assessed initially and at least weekly, including detailed documentation of the wound's characteristics. However, upon admission, Resident R42's pressure ulcer was inaccurately documented as a stage two ulcer, despite hospital records indicating it was a stage three ulcer with macerated, weeping skin and macules and papules around the edges. This discrepancy in documentation and assessment was confirmed by the Infection Control Licensed Practical Nurse (ICLPN). Resident R42 was admitted with a stage three pressure injury to the coccyx, as documented in hospital records, which included specific details about the wound's size, depth, and condition. However, the facility's initial assessment on the day of admission incorrectly documented the wound as a stage two ulcer, with different measurements and lacking a comprehensive assessment. This failure to accurately assess and document the pressure ulcer upon admission was identified during a review of the clinical records and confirmed through staff interviews.
Plan Of Correction
a. Resident 42 no longer resides in the facility. b. Director of Nursing/Designee will audit all residents with pressure ulcers to verify the last assessment and MDS are consistent for accuracy in a 90-day look back period. c. Director of Nursing/designee will educate nursing staff on pressure ulcer documentation, staging, and F686. d. Director of Nursing/designee will audit 5 random pressure ulcers to ensure documentation in assessments and MDS are consistent with the documentation from the wound nurse practitioner and accurate weekly times 4 weeks and monthly times 2 months. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.