Failure to Document and Notify Regarding Pressure Injury
Penalty
Summary
Licensed nursing staff failed to maintain complete and accurate progress notes in accordance with accepted professional standards for a resident with dementia, a history of pressure ulcers, and contractures. The resident, who was unable to make independent medical decisions and had a Power of Attorney for Health Care, developed a pressure injury on the left iliac crest. Despite the facility's policy requiring immediate assessment, documentation, and notification upon discovery of a pressure injury, there was no documentation of the wound or wound care in the medical record prior to a specific date, even though weekly skin assessments were marked as having no areas of skin impairment. Multiple nurses reported that they were instructed by the ADON and DON not to document the wound, not to open a skin event, and not to notify the physician or the resident's family. These instructions led to the provision of wound care without a physician order and without any documentation in the resident's medical record for approximately a month. The nurses expressed discomfort and concern about the lack of documentation and the absence of physician orders, but stated they were told to follow these directives. The wound was treated with wound cleanser, Aquacel, and border foam dressings during this undocumented period. The deficiency was further substantiated by interviews with staff who confirmed the presence and treatment of the wound prior to its official documentation. The DON acknowledged being approached by a nurse about the issue but did not follow up with the ADON or investigate further. The ADON denied instructing staff to omit documentation but could not provide evidence of timely physician notification. Facility policy clearly outlined the need for immediate documentation, notification, and care planning for pressure injuries, which was not followed in this case.