Failure to Document Complete Pressure Ulcer Assessments
Penalty
Summary
The facility failed to follow its own policy regarding the documentation of complete pressure ulcer assessments for three residents with pressure ulcers. For one resident admitted with multiple diagnoses including orthostatic hypotension, muscle wasting, pulmonary embolism, dementia, and a stage 3 sacral pressure ulcer, the care plan required weekly wound assessments with measurements and descriptions. However, there was no documentation of a complete admission wound assessment or weekly assessments after a certain date, as confirmed by both the wound care nurse and the DON. Another resident, admitted with a fractured leg, muscle wasting, heart failure, and dementia, had a care plan addressing a deep tissue injury (DTI) to the left heel. The wound care nurse stated that she did not document wound assessments in the EMR, and the DON confirmed that neither an admission nor weekly wound assessments were completed or documented for this resident's DTI. A third resident, with diagnoses including urinary tract infection, muscle wasting, and dementia, developed a stage 4 sacral pressure injury. The care plan required monitoring and documentation of the wound's location, size, and treatment. However, there was no documentation of a weekly wound assessment, including measurements and description, for a specific week when the resident was not seen by the wound doctor. The facility's policy required complete wound assessments on admission and weekly, including specific wound characteristics, but these were not consistently documented for the affected residents.