Failure to Monitor and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to properly evaluate, monitor, and document pressure ulcers for a resident who was at risk for skin breakdown. Upon admission, the resident was assessed as being at risk for pressure ulcer development but had no existing ulcers. The resident was dependent on staff for most activities of daily living and had multiple diagnoses, including hip fracture, diabetes, and end stage renal disease. Despite the facility's policy requiring systematic assessment and documentation, the resident developed a stage 2 pressure ulcer on the right heel, which was not consistently measured or assessed as required. There were significant gaps in documentation, with weeks passing between wound measurements and incomplete assessments of wound characteristics. The resident subsequently developed a pressure ulcer on the left heel, but treatment for this new ulcer was delayed. The documentation continued to lack regular measurements and comprehensive assessments, making it difficult to determine whether the wounds were healing or deteriorating. The right heel ulcer progressed to a stage 3 ulcer with signs of infection, including increased drainage, foul odor, and a larger wound area. Despite the worsening condition, there were still missing measurements and incomplete documentation of the wound's status. Additionally, a dietary recommendation for a nutritional supplement to aid in wound healing was made, but there was no evidence in the medical record that this intervention was implemented. The resident's condition continued to decline, requiring multiple changes in wound care orders and eventually leading to hospitalization for further evaluation. Throughout the course of care, the facility staff failed to ensure weekly assessments, proper documentation, and timely interventions as outlined in their own policies, resulting in the development and worsening of pressure ulcers.