Inaccurate Resident Assessments for Pain and Pressure Ulcers
Penalty
Summary
The facility failed to ensure accurate completion of resident assessments for two sampled residents. For one resident with a history of hemiplegia and secondary bone cancer, nursing staff did not accurately document reported pain levels in the weekly evaluation. Although the resident consistently reported pain on several days, the weekly nurse's evaluation incorrectly indicated no pain during the review period. This discrepancy was confirmed by both the medication administration record and the licensed nurse involved, who acknowledged the inaccuracy. For another resident with hemiplegia and multiple contractures, the weekly nursing assessment failed to document the presence of an unstageable pressure ulcer on the left thumb, despite direct observation and previous progress notes indicating its existence. The licensed nurse confirmed that the assessment was inaccurate for not including the pressure ulcer. Additionally, the change of condition report for this resident was incomplete and inaccurate, as it did not correctly specify the site or description of the pressure ulcer, nor did it include an interdisciplinary team assessment as required. Facility policies reviewed indicated that all areas of assessment forms must be completed without blanks and that assessments must be accurate and conducted by qualified staff. The Director of Nursing confirmed that the expectation is for nursing staff to accurately assess and document all relevant resident conditions, including pain and skin integrity, in both weekly and change of condition evaluations.