Failure to Consistently Assess, Document, and Provide Wound and Perineal Care
Penalty
Summary
The facility failed to consistently assess, measure, and monitor a resident's pressure ulcer, and did not ensure wound dressings were provided as ordered by the physician. One resident with a history of Addison's disease and susceptibility to skin breakdown developed a Stage III pressure ulcer on the back of her right upper thigh after readmission from the hospital. The resident reported that staff did not listen to her instructions on wound dressing application, resulting in dressings that frequently rolled up and came off. She also stated that dressing changes were not performed consistently, and wound care was not always provided as scheduled. Observations confirmed the presence of a worsening wound, and record reviews showed a lack of consistent wound assessment, measurement, and documentation between physician visits, despite facility policy requiring regular monitoring and documentation. Staff interviews revealed that wound care and assessments were primarily performed by a wound care nurse who visited weekly, but measurements were not always taken at each dressing change, and sometimes the nurse did not return to complete wound care if the resident was unavailable. Other nursing staff were expected to perform dressing changes as ordered, but documentation was inconsistent or missing for multiple dates. The resident's wound progressed from improving to worsening over a period of several weeks, as documented by the Wound Clinic physician, with a significant increase in wound size. Facility records and task histories confirmed that dressing changes and wound assessments were not completed or documented as required by physician orders and facility policy. Additionally, the facility failed to ensure proper perineal care for another resident with an indwelling catheter, resulting in the development of a wound on the foreskin. The resident reported inconsistent perineal care and that staff often failed to properly clean the area, especially under the foreskin. Staff were unaware of the wound until it was observed during the survey, and there was no prior documentation or notification regarding the wound. The lack of proper perineal care and failure to identify and document the wound contributed to the resident's condition.