Failure to Document Comprehensive Pressure Ulcer Assessments
Penalty
Summary
The facility failed to provide care and services related to pressure ulcers in accordance with professional standards of practice for one resident. Specifically, the weekly wound assessments for a resident with a chronic, non-healing stage 4 pressure ulcer to the sacrum did not include proper descriptions or measurements of the wound. The assessments lacked documentation of essential wound characteristics such as size, color, drainage, odor, and pain, as required by facility policy. This omission was confirmed through review of the resident's clinical records and interviews with licensed vocational nurses, who acknowledged the absence of these details in the weekly assessments over an extended period. The resident involved was admitted with multiple diagnoses, including chronic systolic congestive heart failure, a stage 4 pressure ulcer of the sacral region, and functional quadriplegia. Observations indicated the resident required total assistance with feeding and was calm and comfortable at the time of the survey. The regional nurse consultant also verified that proper documentation of wound assessments, including all relevant descriptors, was expected but not completed. The facility's policy required comprehensive weekly documentation of wound status, which was not followed in this case.