Failure to Provide Comprehensive Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care and services to prevent the worsening of an unstageable pressure injury for one resident admitted with a right heel wound. During a dressing change, staff did not cleanse the wound before applying a new dressing, and there were no clear wound care orders for cleansing. Staff interviews revealed inconsistent knowledge of wound care protocols, including the use of offloading boots, air mattresses, and repositioning. The resident was identified as being at nutritional risk, and recommendations for wound healing supplements were made, but documentation of consistent interventions was lacking. Review of the resident's records showed incomplete and inconsistent wound assessments, with missing weekly measurements and documentation. The care plan did not reflect any new interventions or changes for wound management since admission, and time frames for monitoring and measuring the wound were not specified. Facility policy required weekly wound assessments and photographs, but these were not consistently documented. The lack of comprehensive wound care documentation and failure to follow established protocols contributed to the deficiency.