Failure to Complete Weekly Pressure Ulcer Assessments
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and monitor a pressure ulcer for a resident with multiple complex medical conditions, including moderate cognitive impairment, multiple sclerosis, peripheral vascular disease, neurogenic bladder, arthritis, Alzheimer's disease, non-Alzheimer's dementia, malnutrition, and localized edema. The resident was identified as being at risk for pressure sores and had an existing stage four pressure ulcer on the left heel. Provider orders and the care plan included specific interventions such as the use of pressure redistribution boots, nutritional supplementation, wound cleansing, and weekly skin audits by licensed staff. Despite these interventions, documentation and interviews revealed that wound assessments were not completed weekly as required by facility protocol and policy. The electronic medical record showed that wound audits were performed on two specific dates, with no assessment documented in the intervening period. Both the assistant director of nursing (ADON) and the director of nursing (DON) confirmed that weekly wound assessments were not conducted as expected, acknowledging that this lapse could hinder the ability to monitor healing and detect complications in a timely manner. The facility's policy on the treatment and prevention of pressure ulcers mandates weekly wound assessments and documentation, including detailed wound descriptions and progress notes. The failure to adhere to this protocol resulted in a lack of consistent monitoring for the resident's stage four pressure ulcer, which could compromise the effectiveness of the treatment plan and the resident's overall skin integrity management.