Failure to Provide Proper Pressure Ulcer Assessment and Documentation
Penalty
Summary
The facility failed to provide necessary wound care and services in accordance with professional standards of practice for two residents with pressure ulcers. For one resident with multiple diagnoses including COPD, hypothyroidism, and a Stage 3 pressure ulcer, the care plan directed weekly skin assessments and wound care per facility guidelines. However, electronic health records showed that weekly nurse skin assessments were either not performed or lacked required wound measurements and descriptions. There was also a delay in initiating the weekly assessments, and some assessments were missing entirely. The facility did not provide a policy related to pressure ulcer monitoring. Another resident, diagnosed with mild protein-calorie malnutrition and cachexia, was admitted with two Stage 2 and one Stage 3 pressure ulcers. The care plan directed weekly skin assessments but did not specify preventative measures for pressure sores. Physician orders were in place for wound care, but documentation in the electronic medical record lacked evidence of wound measurements, wound bed evaluation, and effectiveness of treatments. Weekly skin assessments and skilled evaluations failed to include measurements or descriptions of the wounds. Interviews with nursing staff and administrative nurses confirmed that wound assessments were supposed to include measurements and detailed descriptions, but these were not documented. Staff were unable to determine the healing status of the wounds due to incomplete documentation. The facility did not provide a policy related to pressure ulcer monitoring, and the lack of proper documentation and assessment placed the residents at risk for complications and delayed healing.