Failure to Properly Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to provide pressure ulcer treatment consistent with professional standards of practice for a resident identified as R18. The resident had a history of peripheral artery disease, diabetes mellitus, paraplegia, and a stage four pressure ulcer on the sacrum upon admission. Despite being at risk for developing pressure ulcers, the facility did not conduct a complete assessment of the resident's pressure ulcers. The nursing admission/readmission evaluations were incomplete, failing to document the type, stage, and measurements of the pressure ulcers. This lack of documentation persisted even after the resident was hospitalized for an infection related to the sacral pressure ulcer and developed a new pressure ulcer on the left knee during the hospital stay. The facility's policy required a full assessment of pressure ulcers, including location, stage, length, width, and depth, but these were not documented for Resident R18. The Assistant Director of Nursing confirmed the inaccuracies and incompleteness of the wound assessments. The resident's clinical records lacked evidence of proper wound assessment and documentation, which was only partially addressed in a wound note dated March 13, 2025. This deficiency highlights the facility's failure to adhere to its own policies and professional standards in managing and documenting pressure ulcers.
Plan Of Correction
1. Resident R16 has an updated skin assessment that includes pressure ulcer location, stage, length, width, and depth measurements. 2. All newly admitted residents will have a skin assessment on admission that lists skin alterations to include location, stage, length, width, and depth measurements to ensure that pressure ulcer treatment is consistent with professional standards of practice. 3. Nurse educator/Designee will re-educate the professional nursing staff on the policy for pressure ulcer/skin assessment. 4. The DON/Designee will conduct weekly random audits times 2 months of residents with pressure ulcers and ensure proper documentation. 5. Audit results will be reviewed monthly by QAPI committee.