Failure to Document Wound Measurements and Monitor Weekly Weights
Penalty
Summary
The facility failed to follow its own policies regarding the documentation of wound measurements and the monitoring of weights for a resident admitted with multiple complex medical conditions, including a stage 4 sacral pressure ulcer and severe protein-calorie malnutrition. Upon admission, the wound nurse measured the resident's wound but did not document the measurements, resulting in the absence of baseline data for the wound care team and physician to assess wound progression. The wound nurse practitioner confirmed that no initial wound measurements were available prior to his assessment several days after admission, which hindered the ability to monitor wound improvement or deterioration. Additionally, the facility did not adhere to its policy of obtaining a baseline weight upon admission and conducting weekly weights for the first four weeks. The resident's weights were only recorded on two occasions, missing several required weekly weigh-ins. Both the dietitian and assistant director of nursing acknowledged that these missed weights prevented accurate monitoring of the resident's nutritional status and timely intervention. The physician order sheet and facility policy both specified the need for weekly weights, which was not followed in this case.