Failure to Accurately Assess and Document Resident Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected the resident's health status, specifically regarding the presence of pressure ulcers. A resident was admitted with multiple wounds, including pressure ulcers on the coccyx, both heels, feet, and knee, as documented in the hospital discharge summary and hospice plan of care. Despite this, the significant change Minimum Data Set (MDS) completed by the facility did not indicate the presence of any pressure ulcers or other skin conditions. The MDS nurse relied solely on nursing documentation and did not personally observe the resident's skin or interview the resident about their skin condition, missing the wounds because there were no explicit hospital orders for wound care. Upon observation, the resident was found to have visible pressure ulcers and abrasions on multiple areas, including the sacrum, heels, feet, and toes, with some wounds covered by dressings. The resident experienced significant pain during attempts at repositioning, and staff were unable to complete a thorough skin assessment due to the resident's pain. Subsequent wound evaluations documented several pressure ulcers and abrasions, some of which were in-house acquired. The facility's weekly skin inspection summary confirmed the presence of these wounds, and the in-house wound nurse completed assessments and treatments after the deficiency was identified. Interviews with facility staff revealed that the MDS nurse did not conduct direct skin assessments or pain evaluations, instead relying on existing nursing notes. The DON acknowledged that the nurse missed documenting the wounds, attributing this to the belief that hospice was responsible for wound care. The facility's policy on care planning did not specify the development of a significant change care plan, contributing to the lack of accurate and comprehensive documentation of the resident's wounds.