Failure to Document and Intervene Timely for Pressure Ulcers and Nutritional Needs
Penalty
Summary
The facility failed to ensure proper documentation and timely intervention for pressure ulcers in two residents, resulting in deficiencies in pressure ulcer care and prevention. For one resident with Parkinson's disease and significant mobility limitations, a pressure ulcer on the sacrum/coccyx was first identified as an excoriation and later documented as a stage II pressure ulcer. However, there was no evidence of weekly monitoring or assessment of the wound, and the wound was not referred to the wound care team or physician for nearly two months. During this period, the wound progressed to a stage III ulcer and later became unstageable due to necrosis, with the first wound physician assessment occurring only after significant deterioration. Facility documentation and communication practices were inconsistent, with staff interviews revealing confusion about notification procedures and a lack of clear documentation in the APRN communication book. Another resident, who was at risk for skin breakdown due to decreased mobility and other medical conditions, developed two new stage III pressure wounds. The dietician made a recommendation for increased protein supplementation to promote wound healing, but this recommendation was not implemented until nearly a month later, after a second recommendation was made. There was no documentation of the original dietary recommendation in the resident's chart or the APRN communication book, and staff interviews indicated uncertainty about the process for handling dietary recommendations. The facility was unable to provide a policy outlining how such recommendations should be processed, despite having a protocol that required the dietician to assess and recommend nutritional supplementation as appropriate. Facility policy required regular documentation of wound appearance, weekly progress notes, and prompt referral to the wound care team for wounds not improving within 2-3 weeks. The policy also outlined specific documentation requirements for wound site, stage, size, and appearance, as well as procedures for reporting and treating acquired wounds. Despite these policies, the facility failed to follow its own protocols, resulting in delayed assessment, inadequate documentation, and lack of timely intervention for pressure ulcers and related care needs.