Failure to Provide Daily Monitoring and Assessment of Pressure Ulcer
Penalty
Summary
The facility failed to implement daily monitoring and assessment of a deep tissue injury for a resident who was at moderate risk for pressure ulcers. The resident had multiple diagnoses, including diabetes mellitus and a history of stroke, and required significant assistance with activities of daily living. Upon admission, the resident had no unhealed pressure ulcers, and care plans identified interventions such as regular repositioning, use of pressure-relieving devices, and weekly skin assessments. However, after a pressure wound was identified on the sacrum, documentation showed inconsistent and incomplete monitoring, with several entries lacking details on the wound's condition, such as pain, size, drainage, and tissue description. Nursing staff interviews revealed confusion and lack of clarity regarding the assessment and documentation of the pressure ulcer. Some staff were unaware of the wound, while others could not recall or describe its characteristics. There were no clear orders for daily wound observation or treatment, and the wound was not consistently evaluated or documented each day. The facility's policy required weekly wound assessments but did not specify daily monitoring for existing pressure ulcers, contributing to the lack of consistent care. The resident's medical record lacked evidence of daily monitoring of the pressure ulcer, and the wound was ultimately described as a severe decubitus ulcer upon transfer to the emergency room. The deficiency was further highlighted by the absence of clear documentation and communication among staff regarding the wound's status and the lack of a specific treatment plan or daily assessment orders in the resident's records.