Failure to Complete Pressure Ulcer Assessment and Timely Care Plan
Penalty
Summary
The facility failed to perform a thorough pressure ulcer assessment and to initiate a baseline care plan for a resident who was admitted with a pressure ulcer. Upon admission, the resident's assessment noted a pressure area to the sacrum, but there was no further description or measurement of the wound. The electronic medical record and progress notes lacked a detailed initial or weekly assessment of the pressure ulcer, including essential information such as measurements, appearance, wound bed, wound edges, and drainage. The weekly skin check only indicated an open area to the sacrum without further assessment details. Despite physician orders for a wound care consult and wound care to the sacrum, the resident's skin integrity care plan was not initiated until eight days after admission, and the care plan details were incomplete. Interviews with nursing staff and the wound care nurse confirmed that the initial wound assessment was insufficient and did not meet facility policy requirements. Staff acknowledged that a baseline care plan should have been initiated within 24-48 hours of admission and that proper documentation is critical for tracking wound progress and ensuring continuity of care. The facility's own policy required comprehensive documentation of pressure injuries, including wound type, location, stage, measurements, wound bed and edge descriptions, drainage, and pain assessment. However, these requirements were not met for the resident in question, as confirmed by both the Director of Nursing and the wound care nurse, who were unable to locate any detailed wound assessment in the resident's record. This lack of thorough assessment and timely care planning constituted a deficiency in the facility's pressure ulcer care process.