Failure to Conduct Timely Pressure Ulcer Assessment
Penalty
Summary
The facility failed to ensure a timely and thorough assessment of pressure ulcers upon admission for one resident. The resident, who was admitted with multiple diagnoses including malignant neoplasm of the bladder, malnutrition, and abscesses, was found to have a stage III pressure ulcer on the sacrum. However, the RN responsible for the admission did not document a comprehensive wound assessment, including specific measurements and a detailed description of the wound, as required by facility policy. Four days after admission, a contracted wound care specialist identified a stage IV pressure ulcer on the resident, which had progressed to full-thickness tissue loss with exposed bone, tendon, or muscle. The wound was measured at 5.0 cm in length, 3.0 cm in width, and 0.5 cm in depth, with a calculated area of 15 square centimeters. The facility lacked documentation to show that a timely and thorough assessment was conducted by an RN upon admission. Interviews with the Director of Nursing confirmed that the facility's expectation was for an RN to complete a thorough wound assessment upon admission, including measurements and wound description, to be documented in the resident's clinical record. The facility acknowledged the failure to meet this expectation, resulting in a deficiency in resident care policies and nursing services as per state regulations.