Failure to Assess, Document, and Treat Pressure Ulcer on Admission
Penalty
Summary
The facility failed to properly assess and document a resident's skin condition upon admission, as well as to conduct and record weekly skin assessments as required. The resident was admitted with a diagnosis that included a stage 2 pressure ulcer, but there was no documentation of an admission skin assessment in the medical record, and the initial progress note referenced an admission assessment that could not be located. The CNA Skin Attention Form and the Director of Nursing's signature indicated awareness of the pressure ulcer, but the physician was not notified for treatment orders at the time of admission, and no pressure ulcer treatment was present on the physician's order sheet. Further review of the resident's records showed inconsistent documentation of weekly skin assessments, with some entries made in the Treatment Administration Record and others missing from the computer system. Staff interviews revealed that agency nurses sometimes skipped the admission assessment or documented it inconsistently, and there was confusion about where to record weekly skin assessments. The wound nurse and DON both described expectations for timely and thorough skin assessments, but these were not consistently met, and the wound nurse did not document or assess pressure ulcers after a facility-wide skin sweep. The facility's own policy required a skin assessment at admission, weekly licensed nurse assessments, and prompt physician notification and documentation when pressure ulcers are identified. Despite these requirements, the resident's pressure ulcer was not properly assessed, measured, or documented upon admission, and there was a delay in initiating appropriate treatment orders. The lack of consistent documentation and communication among staff contributed to the deficiency in pressure ulcer care and prevention.