Failure to Monitor and Document Pressure Ulcer Progression
Penalty
Summary
Treatment Nurse 1 (TN1) failed to monitor and document the progression of pressure ulcers for a resident who was readmitted with multiple complex diagnoses, including metabolic encephalopathy, dementia, HIV, chronic respiratory failure, congestive heart failure, and dysphagia. The resident was identified as having two unstageable pressure ulcers—one on the medial back and one on the coccyx—both related to immobility. The care plan required weekly documentation of wound measurements, descriptions, and monitoring for changes, but this was not completed as required. The last documented Pressure Sore Skin Problem Report for the resident was completed on 2/28/2025, with no subsequent reports found in the record. TN1 acknowledged during an interview that he was responsible for monitoring and documenting the resident's pressure ulcers weekly but admitted to falling behind due to feeling overwhelmed by the volume of required documentation. Both TN1 and the Director of Nursing (DON) confirmed that weekly documentation was necessary to track the progression of the wounds and ensure appropriate treatment. A review of the facility's policy and procedure confirmed the expectation for nursing staff to assess and document pressure ulcers, including location, stage, measurements, and other relevant factors. The lack of ongoing weekly documentation and monitoring for this resident's pressure ulcers constituted a failure to follow the care plan and facility policy, with the potential for the resident's pressure ulcers to worsen.