Failure to Accurately Monitor, Document, and Care Plan Pressure Ulcer
Penalty
Summary
The facility failed to provide the highest quality of care by not accurately and completely monitoring and documenting wounds for a resident at risk for pressure ulcers. Despite the facility's policies requiring weekly wound assessments, documentation of wound descriptors, and care planning for all wounds, there were multiple instances where these protocols were not followed. The resident, who had diagnoses including multiple sclerosis, hypertension, and kidney failure, was assessed as being at moderate risk for pressure ulcers and required substantial to maximum assistance for mobility. Upon re-admission, the resident developed a new open sore on the left buttock, which was documented and treated per physician orders, but subsequent weekly skin assessments failed to consistently identify or document the wound. Review of the resident's records showed that weekly skin assessments often indicated no skin issues, even after the wound was identified, and there were missed or refused assessments that were not followed up appropriately. The care plan did not address the resident's wound or its treatment, despite the presence of a physician order for wound care. Additionally, there was a missed wound care treatment with no supporting documentation, and after a certain date, no further skin assessments were documented in the electronic medical record. Interviews with staff, including the DON, ADON, LPNs, and the MDS/Care Plan Coordinator, revealed inconsistencies in completing weekly skin assessments and a lack of clarity regarding responsibility for wound measurement and documentation. The resident reported having to request wound care from staff, expressed concerns that wound care was not performed as required, and believed that staff did not measure the wound weekly. Observations confirmed the presence of open areas and non-blanchable redness on the resident's buttocks. Staff interviews corroborated that weekly skin assessments were not consistently completed, wounds were not always care planned, and floor nurses did not measure wounds. The facility did not have a current wound care nurse, and the DON was expected to assume those responsibilities.