Failure to Assess, Document, and Prevent Pressure Ulcers
Penalty
Summary
The facility failed to ensure comprehensive assessment and documentation of pressure ulcers for two residents upon admission and on a weekly basis, as well as failed to implement interventions to prevent the development of a pressure ulcer for another resident. For one resident with multiple comorbidities including spinal stenosis, diabetes, and recent surgery, the initial wound assessments were incomplete, lacking proper staging, detailed descriptions, and consistent measurements. The wound nurse was reportedly inexperienced and uncomfortable with staging, resulting in delayed and inadequate documentation. Physician-ordered treatments were not implemented promptly, and wound care was not always appropriate for the stage of the ulcer. Another resident with a history of severe medical conditions and high risk for skin breakdown was admitted and readmitted with skin impairments, including abrasions and moisture-associated skin damage (MASD). The facility did not provide comprehensive assessments of these wounds, often omitting location, measurements, staging, and descriptions. Weekly wound observations were incomplete, and there was a consistent failure to determine whether wounds had improved, deteriorated, or remained unchanged. Documentation was insufficient, and the care plan interventions were not always based on thorough wound assessments. A third resident, who was at risk for pressure ulcers and required significant assistance with mobility and hygiene, developed a new pressure ulcer after admission. The facility did not implement timely interventions such as regular turning and repositioning, despite recommendations from a prior wound care consult. Documentation of the new ulcer lacked staging and pain assessment, and the care plan was not updated with new interventions until after the ulcer developed. Observations showed the resident frequently left in bed with the head elevated and expressing discomfort, with staff interviews confirming that repositioning was not consistently performed or documented.