Failure to Complete Weekly Wound Assessments for Pressure Ulcer
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident with a history of a Stage IV sacral pressure ulcer. The resident was admitted with this condition and later readmitted following a hospitalization. Medical record review revealed that staff did not complete required weekly wound assessments with measurements on multiple occasions, specifically on 12/23/22, 12/30/22, 1/13/23, 2/17/23, and 3/3/23. The absence of these weekly wound assessments impeded the ability to monitor the wound's progress, identify any issues that could affect healing, and ensure the effectiveness of the treatment plan. This deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged the lack of documented weekly wound assessments for the resident's sacral pressure ulcer.