Failure to Consistently Assess and Document Wound Care
Penalty
Summary
The facility failed to provide consistent wound assessments for a resident with moisture-associated skin damage (MASD) on the buttocks, as required by the facility's policy and procedure. The resident, who had a history of peripheral vascular disease and chronic obstructive pulmonary disease, was admitted with a physician's order for daily wound care and a reevaluation after 21 days. However, a review of the medical record revealed that there were no documented assessments of the wound for two consecutive weeks, despite the ongoing treatment. During interviews and record reviews, a licensed vocational nurse confirmed the absence of wound assessment documentation for the specified weeks and acknowledged the importance of such documentation in guiding care and monitoring the wound's progress. Observations confirmed the presence of scattered areas of skin redness and shallow open areas on the resident's buttocks. The facility's policy required weekly head-to-toe assessments by licensed nursing staff, which were not completed as documented for the resident during the identified period.