Failure to Document and Communicate Pressure Ulcer Assessment and Interventions
Penalty
Summary
A deficiency occurred when the facility failed to document weekly assessments and the healing process of a newly identified non-blanchable area of redness on the sacrum for one resident. The resident, who had a history of hemiplegia, insulin-dependent diabetes, and dementia, was at moderate risk for pressure ulcers and required significant assistance with activities of daily living. A non-blanchable area was discovered during incontinent care, and initial interventions such as a specialty mattress, turn and positioning schedule, and barrier paste were planned. Despite these interventions, the clinical record did not show evidence that a physical or occupational therapy evaluation was requested or completed, nor that a specialty mattress was implemented. There was also no documentation of further assessments of the sacral area after the initial finding, nor any record of physician or resident representative notification regarding the new skin issue. The facility's treatment administration record indicated that weekly skin checks were signed off, but there was no specific observation documentation of the sacral area. Interviews with facility staff confirmed that the wound nurse and the advanced practice registered nurse were not notified of the new skin issue, and the resident was not added to the weekly wound rounds for further evaluation. The facility's policy required assessment and documentation of significant risk factors and physician involvement in identifying and managing pressure ulcers, but these steps were not followed as documented in the clinical record.