Failure to Document Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to ensure that a resident's pressure ulcer was evaluated and monitored at least weekly, as required by both facility policy and regulatory standards. The resident in question had an unstageable pressure ulcer with eschar on the left heel that was present upon admission. The care plan specified that the location, size, and treatment of the skin injury should be monitored and documented, with weekly treatment documentation to include measurements and descriptions of the wound. Despite these requirements, multiple record reviews revealed a lack of documentation regarding the evaluation, measurement, or description of the left heel pressure ulcer. The electronic medical record, skin checks, total body skin assessments, progress notes, and medication administration records all failed to include the necessary details about the wound's size or condition. Observations confirmed the ongoing presence of the wound, but there was no evidence that staff had completed or recorded the required weekly assessments. Interviews with facility staff, including the DON, ADON, and an LPN, confirmed that the expected documentation was missing. The DON acknowledged that there was no documentation of evaluations or measurements for the resident's left heel wound, despite the facility's policy and the ongoing presence of the unhealed pressure ulcer.