Failure to Document Wound Measurements During Initial Assessment
Penalty
Summary
The facility failed to ensure that two residents received wound care in accordance with professional standards of practice by not measuring their wounds during the initial assessment of new abrasions. For both residents, the Non-Pressure Sore Skin Problem Reports documented the presence of new right arm abrasions but did not include any measurements of the wounds. Physician orders were in place for daily wound care, but the initial wound size was not recorded. Treatment nurses confirmed during interviews that they did not document wound measurements at the time of the initial assessment, and the Director of Nursing acknowledged that wounds should have been measured on the day they were first assessed to establish a baseline for monitoring progress. Both residents had significant medical histories and cognitive impairments. One resident had diagnoses including encephalopathy, heart disease, and vascular dementia, with severely impaired cognition and moderate assistance required for most ADLs. The other resident had type two diabetes mellitus, schizoaffective disorder, and reduced mobility, with severely impaired cognition and complete dependence on staff for most ADLs. The facility's policy required documentation of all wound assessment data, including size, but this was not followed for the new wounds identified in these residents.