Failure to Accurately Assess and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess and monitor pressure ulcers for a resident with multiple medical conditions, including severe cognitive impairment, COPD, dementia, and a history of falls. The resident was admitted with significant risk factors for skin breakdown and was documented to have pressure injuries on the left gluteus and coccyx. Multiple Skin and Wound Evaluation forms were completed over several weeks, but the documentation was inconsistent and inaccurate. Wound measurements were sometimes combined for separate wounds, and at times, the assessments did not match the photographic evidence, with some wounds not being individually measured or properly classified. Interviews with the wound nurse revealed a lack of clarity and understanding regarding the documentation and assessment process. The wound nurse was unable to explain why wounds were recorded as a single injury when photographs showed two distinct wounds, or why some wounds were not measured separately. Additionally, the wound nurse could not account for discrepancies between the documented wound locations and the actual wounds observed in photographs. The plan of care for the resident was also found to be inaccurate, as it did not reflect the presence of both pressure ulcers or indicate when a wound had healed. The Director of Nursing confirmed that the wound assessments and the resident's plan of care were not completed accurately. Observations of wound care revealed that only the coccyx wound was present and treated, while the left gluteal area was intact. The documentation, however, did not consistently reflect these findings, and the plan of care was not updated to accurately represent the resident's current wound status.