Failure to Complete Pressure Ulcer Assessment Upon Discovery
Penalty
Summary
A deficiency was identified when the facility failed to ensure a thorough assessment of a pressure ulcer upon its discovery for one resident. The resident, who had multiple diagnoses including dysphagia, COPD, chronic venous hypertension with bilateral lower extremity ulcers, peripheral vascular disease, and a below-the-knee amputation, was dependent on staff for most activities of daily living. Physician orders were in place to reduce pressure on the right heel and left stump by floating them off the bed at all times. On a specific date, wound care was provided to the right heel, and a treatment order was initiated. However, subsequent skin observation tools did not document new skin concerns, and a wound observation tool later noted a pressure wound to the right heel without staging or a complete assessment. Interview with an LPN confirmed that when the wound on the right heel was first found, no assessment was documented in the medical record to include measurements or a description of the wound bed. The LPN described the wound as 100% black necrotic tissue, dry, and without drainage, and acknowledged that it was expected to complete a change in condition or skin assessment with measurements and description when a new wound was found. The facility was unable to provide a policy for documentation requirements for new pressure wounds.