Failure to Ensure Accurate Assessment and Documentation of Pressure Wounds
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident with multiple complex medical conditions, including end stage renal disease, diabetes, cognitive impairment, and multiple pressure wounds. Upon admission, the resident's skin assessment did not document wounds on the coccyx or right flank, and the Minimum Data Set (MDS) did not reflect the presence or stage of these pressure injuries. Subsequent weekly skin assessments identified new wounds that were not present in the initial assessment, and the care plan was not updated to include these findings as of several days later. Observations revealed the resident was often found lying in bed with heels directly on the mattress and without appropriate offloading devices for pressure wound prevention. Interviews with nursing staff indicated that wound assessments were performed using a tablet application, but staff acknowledged that the accuracy of wound measurements and documentation could be compromised by user technique. There was inconsistency in wound staging and documentation, with discrepancies noted between staff descriptions and electronic records, including conflicting reports of wound characteristics such as the presence of slough or eschar. Further interviews with facility leadership and external vendors revealed a lack of formal wound staging training for staff, with education being provided by a dressing supply vendor who did not directly train staff on staging. The risk manager and DON were unaware of certain wound developments, and the resident's physician and physician assistant had not been informed of significant changes in the resident's wound status. The dressing supply vendor clarified that she only provides suggestions and does not assess or stage wounds, and had not observed staff performing wound assessments in several months.