Failure to Complete and Document Pressure Ulcer Care and Skin Assessments
Penalty
Summary
The facility failed to ensure that wound care treatments were completed and properly documented, including weekly wound tracking and measuring, for a resident with multiple pressure ulcers. Specifically, one resident admitted with diagnoses including dementia, diabetes mellitus, and hypertension, was under hospice care and had several pressure ulcers at various stages. The facility's records showed missed or undocumented wound care treatments over several shifts, and only one instance of wound measurement was documented by facility staff, despite policy requiring weekly assessments and documentation. Interviews with staff revealed confusion over responsibilities between hospice and facility staff, and a lack of consistent documentation of wound care and measurements. Another resident, admitted with diabetes, fibromyalgia, rheumatoid arthritis, and a history of toe amputation, was at risk for developing pressure ulcers and had a Stage III pressure ulcer upon admission. The facility failed to complete and document weekly skin assessments for this resident, with a gap in full body skin assessments noted in the records. Additionally, this resident did not have a care plan focus for skin impairment, contrary to facility policy and staff expectations. Interviews with nursing staff and the DON confirmed that wound care and skin assessments were expected to be completed and documented according to policy, but these actions were not consistently carried out. Staff cited workload and time constraints as reasons for missed documentation, and there was uncertainty about whether treatments were being performed or simply not recorded. The DON acknowledged the lack of daily wound documentation and incomplete care planning for the resident at risk, as well as the need for both hospice and facility staff to be involved in wound measurement and documentation.