Failure to Complete and Document Pressure Ulcer Interventions and Assessments
Penalty
Summary
The facility failed to ensure that interventions and treatments for pressure ulcers were completed for a resident with significant medical conditions, including type 2 diabetes mellitus, morbid obesity, osteomyelitis, and chronic embolism. The resident had a stage 4 pressure ulcer to the sacrum and a pressure injury to the right hip, with care plans and physician orders specifying interventions such as vital sign monitoring, use of a low air loss mattress, regular wound assessments, and specific wound care treatments. However, the record lacked documentation that vital signs were consistently obtained as ordered, with the last recorded blood pressure noted several months prior, despite vital sign monitoring being a care plan intervention for both skin impairment and osteomyelitis. There were multiple instances where wound care and daily wound assessments were not documented for both the sacrum and right thigh wounds on specified dates. Additionally, the care plan intervention for a low air loss mattress remained active in the resident's record and was documented as checked by staff every shift, even after the mattress had been removed at the resident's request. This discrepancy indicated that staff continued to document compliance with an intervention that was no longer in place, and the care plan was not updated to reflect the change. Furthermore, wound care and dressing changes were not consistently documented as completed according to physician orders. Observations also revealed that wound dressings were not dated during wound care procedures, and there was no wound care policy provided by the facility. Interviews with staff confirmed that the resident refused the low air loss mattress due to discomfort, but the care plan and electronic records were not updated accordingly. The lack of documentation and failure to follow through with ordered interventions and assessments contributed to the deficiency in providing appropriate pressure ulcer care and prevention.