Failure to Document Wound Assessments and Responses to Treatment
Penalty
Summary
The facility failed to adequately document wounds and responses to treatment for a resident with a history of peripheral vascular disease and foot pain. A change in condition was identified when a new open wound appeared on the resident's left lower extremity, and a skin assessment was performed. However, the assessment did not include documentation of the wound's size or characteristics. An order for wound care was written, but subsequent skin assessments continued to lack detailed documentation regarding the wound's measurements or characteristics. Further changes in the resident's condition were noted, including the development of a new wound on the right leg, with descriptions of wet dressings, foul odor, and significant pain. Both lower extremities were found to have soaked dressings with serosanguinous drainage and foul odor, and the right second toe was noted to have drainage and black discoloration. Despite these findings, the facility's documentation did not meet its own policy requirements for complete wound assessment, which include type, stage, measurement, and description of wound characteristics.