Failure to Consistently Monitor and Document Pressure Ulcers
Penalty
Summary
The facility failed to ensure consistent weekly monitoring and measurement of pressure ulcers for a resident with significant cognitive and physical impairments. The resident had a history of moderately impaired cognition, delusions, paranoid schizophrenia, PTSD, upper extremity impairment, and required substantial assistance with mobility and hygiene. Physician orders and the care plan specified that wounds on the resident's buttocks were to be measured weekly and documented, with additional instructions for regular dressing changes and skin checks. Despite these orders, documentation in the resident's medical record showed multiple instances where wounds were not monitored or measured as required. Specific dates in May and June lacked evidence of wound assessment or measurement, and there were gaps in progress notes regarding the condition of the pressure ulcers. Interviews with nursing staff and the DON confirmed that nurses were responsible for weekly skin checks and documentation, and that these tasks were not consistently performed or recorded. The DON acknowledged that there was no formal wound care program and that documentation was missing for several weeks. The facility's own policy required appropriate staff to provide treatment and services to heal pressure ulcers and prevent further development, but the lack of consistent monitoring and documentation demonstrated a failure to follow these protocols. The deficiency was identified through interviews, document review, and direct observation of the resident's medical record, which showed a pattern of missed or incomplete wound care documentation.