Failure to Document and Monitor Pressure Ulcer Care
Penalty
Summary
Facility staff failed to provide care and services consistent with professional standards of practice to prevent and treat a pressure ulcer for a resident with paraplegia, diabetes mellitus II, and existing pressure ulcers on the sacral region and left ischium. The facility's policy required documentation of any change in the resident's condition, all assessment data obtained during wound inspection, the type of wound care provided, and the date and time of care. However, review of the Treatment Administration Record (TAR) for a specified period showed that there was no documentation of wound characteristics or evaluation and monitoring of the left ischial wound on several dates. Additionally, skin assessments during this period did not indicate any evaluation or monitoring of the wound's characteristics. Interviews with the DON confirmed that staff were expected to document wound descriptions on the TAR with every dressing change, including details about the wound bed, drainage, and signs of infection. The DON acknowledged that there was no wound documentation entered on the TAR for the left ischial wound during the specified dates, despite the expectation that such documentation should have been completed. This lack of documentation meant that wound changes could not be identified, and the wound's status was not properly evaluated or monitored.