Failure to Timely Assess and Document Pressure Ulcer
Penalty
Summary
A resident with severe protein-calorie malnutrition and impaired cognition was admitted to the facility without any open pressure ulcers, as confirmed by an initial skin assessment conducted by the wound care team. Preventative measures, including a pressure-reducing mattress and repositioning protocols, were implemented due to the resident's decreased mobility. However, the resident later developed an open area on the coccyx and groin, which was first identified by a CNA and subsequently treated by nursing staff with cleansing, application of Medihoney, and a foam dressing. The medical doctor was notified, and a wound care consult was requested. Despite the development of the pressure ulcer, there was no evidence in the medical record that the wound was timely assessed, staged, or measured by the wound care team or licensed nurse, as required by facility policy. The wound care nurse stated that they were waiting for the wound care nurse practitioner, who visits weekly, but the practitioner did not assess the wound before the resident was transferred to the hospital. Wound care notes were requested but not provided by the end of the survey.