Failure to Accurately Assess and Document Pressure Injury Care
Penalty
Summary
The facility failed to provide necessary care and services to promote healing and prevent the development of pressure injuries for a resident admitted with a pressure injury (PI) on the left heel. The facility did not complete accurate and comprehensive assessments of the resident's left heel PI as required by their own policy, which mandates weekly wound assessments and proper documentation of wound characteristics. Medical records showed inconsistencies in the assessment of the wound, including discrepancies in the type of tissue present and changes in the staging of the PI without clear documentation. The resident's PI progressed from a stage 1 to an unstageable wound, with incomplete information regarding the wound's tissue composition. The resident had multiple diagnoses, including diabetes mellitus, chronic kidney disease, and dementia, and was admitted with a left heel PI. The facility lacked wound care certified nurses and relied on an external wound care provider for weekly rounds, but the resident was followed by an outside wound clinic instead. The facility's documentation and assessment practices did not align with their policy or with best practices for pressure injury management, as evidenced by incomplete and inaccurate wound assessments during the resident's stay.