Failure to Document New Wound Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment and documentation of a new wound for a resident, identified as Resident #25, who was admitted with multiple diagnoses including dysphagia, chronic obstructive pulmonary disease, and peripheral vascular disease. The resident was cognitively intact and required varying levels of assistance with daily activities. A physician's order was in place to reduce pressure on the resident's right heel and left stump. However, when a wound was discovered on the resident's right heel on February 11, 2025, the facility did not document an assessment of the wound, including measurements and a description of the wound bed, in the medical record. Interviews with a Licensed Practical Nurse (LPN) confirmed that the wound was not assessed or documented as required, and the wound bed was described as 100% black necrotic tissue and dry, with no drainage. The facility was unable to provide a policy for documentation requirements for a new wound. This deficiency was identified during an investigation under Complaint Numbers OH00164982 and OH00164075, indicating non-compliance with the requirement to document new wounds accurately.