Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents, as evidenced by incomplete documentation of wound treatments, lack of weekly skin assessments, and failure to follow physician orders for pressure ulcer management. For one resident, the care plan identified a risk for skin breakdown due to impaired mobility and incontinence, with interventions such as weekly skin checks and administration of treatments as ordered. However, the Medication/Treatment Administration Records (MAR/TAR) showed multiple missed or undocumented wound care treatments on specified dates, and there was no evidence that weekly skin assessments were consistently performed. Another resident, who was readmitted without any pressure injuries and identified as high risk for pressure ulcer development, developed a facility-acquired unstageable/stage 4 pressure ulcer. Documentation revealed that skin assessments were not consistently completed, and the wound was only identified after a certified nursing assistant reported it to a nurse. Subsequent wound assessments and physician notes detailed the progression of the wound, including the presence of necrotic tissue, infection, and the need for surgical debridement. There were also discrepancies in documentation regarding antibiotic administration and wound cultures, as well as evidence that the resident did not consistently receive ordered wound care treatments. Interviews with facility staff indicated that staffing shortages and lack of management support contributed to missed wound care and declining wound conditions. The facility's own policies required licensed nurses to document medication and treatment administration, and to follow physician orders for wound care, but these procedures were not followed. The surveyor determined that these failures resulted in significant harm, including the development of a severe, infected pressure ulcer that required hospitalization.