Failure to Accurately Assess and Document Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards of practice to prevent and manage a pressure injury (PI). Specifically, the nursing staff did not perform an accurate assessment of the resident's pressure injury on the right buttock. The wound was initially documented as a stage 2 PI, later as an unstageable PI, and then incorrectly reclassified as a stage 2 PI, which constitutes reverse staging—a practice not permitted by professional standards. Multiple registered nurses and the Director of Long-Term Care confirmed during interviews that the wound should have been documented as a healing unstageable PI rather than being restaged to a lower classification. The resident involved had a history of dementia, major depressive disorder, and mobility abnormalities, and required significant assistance with activities of daily living, including total assistance with toileting, hygiene, bathing, and transfers. The resident's clinical records indicated severe cognitive impairment but retained the ability to communicate needs. The wound care assessments were completed weekly by registered nurses and documented in the facility's electronic health record, but the documentation failed to accurately reflect the wound's progression and stage. Facility policy required accurate and complete documentation of pressure injuries, including proper staging and ongoing evaluation. The failure to accurately assess and document the pressure injury as healing unstageable, rather than incorrectly restaging it as stage 2, meant that the resident was at risk for inappropriate treatment and potential worsening of the wound. This deficiency was confirmed through record review and staff interviews, which acknowledged the error and the importance of proper wound assessment and documentation.