Failure to Assess, Document, and Treat Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess, document, and initiate treatment for a resident with multiple pressure injuries upon admission. The resident, who had a history of dementia, hypertension, type 2 diabetes, and chronic kidney disease, was admitted with a stage 1 pressure injury to the coccyx, bruising to the left elbow, and pressure injuries to both feet. The nursing admission assessment did not specify the stage or measurements for the toe injuries, and there was no treatment order for the coccyx wound. Additionally, the physician's admission note did not mention any of the identified wounds, and there was no ongoing documentation or monitoring of the coccyx pressure injury in the nursing progress notes or skin/wound assessments for several days following admission. Subsequent documentation revealed that the resident developed moisture-associated skin damage (MASD) to the coccyx and buttocks, with a new wound identified later, but without detailed assessment or documentation of the wound's characteristics. During an observation, a probable stage 2 pressure injury was found near the anus, and the nurse did not measure the wound. The resident reported that wound care was not provided every shift as ordered. These failures in assessment, documentation, and timely intervention resulted in the worsening of the resident's coccyx wound.