Failure to Document and Assess New Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer received the necessary treatment and services consistent with professional standards of practice. Specifically, when a new wound was identified on the resident, the Treatment Nurse did not measure or adequately document the wound in the electronic medical record (EMR) at the time it was first found. Although the wound was discovered and treatment orders were entered, the required initial wound assessment and documentation, including measurements, were not completed as per facility policy. The resident involved was a female with significant medical and cognitive impairments, including major depressive disorder, Down syndrome, and a history of urinary tract infections. She was always incontinent of bowel and bladder and required moderate assistance with activities of daily living. The wound, located on the back of her right thigh near the gluteal fold, was described as a shallow, pink/red, moist area consistent with a stage 2 pressure injury. Staff interviews revealed that the wound had been present for at least two weeks, and there was confusion among staff regarding the exact timeline and responsibility for documentation. Multiple staff members, including CNAs and nurses, acknowledged awareness of the wound but failed to ensure timely and complete documentation in the EMR. The Treatment Nurse admitted to not completing the wound assessment form and stated that she had the measurements but did not enter them into the system. The facility's policy required that any newly identified wounds be assessed and documented by the Treatment Nurse or charge nurse, with measurements recorded and care plans updated accordingly. The lack of documentation meant that the wound's progression could not be properly monitored, as confirmed by interviews with the Interim DON and Regional Director of Clinical Services.