Failure to Assess and Document Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to properly assess and document a pressure ulcer for one resident with significant comorbidities, including congestive heart failure, atrial fibrillation, and osteomyelitis. The resident, who had moderate cognitive impairment and required partial to moderate assistance, developed a facility-acquired stage 4 coccyx wound. Despite the facility's policy requiring prompt identification and documentation of skin breakdown, there was a lack of timely and consistent wound assessments, with only one skin evaluation provided for several months and no clear record of when the wound first appeared. Staff interviews revealed confusion and lack of knowledge regarding the resident's wound status, weight loss, and pain management. The assigned nurse was unable to describe the wound or provide information on the resident's nutritional intake, and the wound care nurse was uncertain about the duration of the wound prior to notification. The Director of Nursing stated that nurses were not expected to complete skin assessments and that skin assessments were not entered as orders, relying instead on CNAs to notify nurses of any skin impairments. However, documentation supporting regular skin checks was lacking. Further review showed that the resident's wound was not included on the facility's pressure ulcer list until specifically requested by surveyors, and there were gaps in pain management orders and weight monitoring. The wound was described as unstageable with visible muscle, foul odor, and purulent discharge upon hospital transfer. The facility's failure to follow its own policy for wound identification, documentation, and treatment led to a delay in appropriate care for the resident's pressure ulcer.