Failure to Accurately Complete Comprehensive Assessment for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to accurately complete a comprehensive assessment for one resident upon admission and during subsequent assessments. The resident, who had diagnoses including muscle weakness, contractures in both legs, dementia, and pressure-induced deep tissue damage of the left heel, was admitted and later readmitted to the facility. Upon observation, the resident was found wearing pressure-relieving boots, with one boot nearly detached. Family interview confirmed the resident was unable to move his legs due to muscle atrophy and contractures, and had developed a sore on his heel. Medical records and wound care notes documented an unstageable pressure ulcer on the left heel, with specific measurements and wound characteristics provided by outside wound care services. Despite this documentation, the facility's Quarterly Minimum Data Set (MDS) assessment did not accurately reflect the presence of the unstageable pressure ulcer, as the relevant section was marked as having no such ulcer. This discrepancy between the wound documentation and the MDS assessment demonstrates the facility's failure to complete a comprehensive and accurate assessment of the resident's condition as required.
Plan Of Correction
F636 – Comprehensive Assessments & Timing Element #1: R20's comprehensive assessment and care plan were updated and completed. R20 was assessed by the Director of Nursing and/or designee to ensure no lasting effects related to the inaccurate assessment. Element #2: An audit of all residents admitted in the past 6 months was conducted by the MDS Coordinator and/or designee to ensure that comprehensive assessments were completed on time and accurately. Element #3: The Administrator reviewed the regulation F636, and education was provided to Licensed Nurses and Department Managers on the regulation and guidelines. Element #4: The MDS Coordinator and/or designee will review the assessment tracker weekly for 12 weeks to verify timely completion and accuracy of comprehensive assessments. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025