Failure to Prevent Worsening of Pressure Ulcer Due to Incomplete Assessment and Documentation
Penalty
Summary
A resident was admitted with three Stage II pressure ulcers located on the right buttock, right hip, and left buttock. Over time, the pressure ulcer on the right buttock worsened to a Stage III. Staff interviews revealed that the resident was to be repositioned every two hours and provided with nutritional support, including assistance with eating and increased Glucerna intake after refusing another supplement. Wound care was performed regularly, and the wound was measured weekly by a designated staff member. However, there was inconsistency in wound assessment documentation, with a gap in skin assessments from 11/26/24 through 1/13/25, and requested documentation for debridement notes was not provided. Staff also reported that the wound had become infected and was treated with antibiotics. Review of the resident's care plan and medical records showed discrepancies in the staging and documentation of the wounds, with the care plan not consistently reflecting the current status or treatment of the pressure ulcers. The facility's wound management policy required weekly full assessments and updates to the care plan, but these were not consistently completed or documented. The lack of consistent and timely wound assessments, incomplete documentation, and failure to update the care plan contributed to the worsening of the resident's pressure ulcer from Stage II to Stage III.