Failure to Complete Required Weekly Pressure Ulcer Assessments
Penalty
No penalty information released
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Summary
A deficiency was identified when a resident with two heel wounds did not receive the required weekly assessments, including measurements and descriptions of the pressure ulcers. Review of the resident's medical record showed inconsistent documentation, with wound assessments recorded on non-weekly intervals and some assessments missing key information such as wound stage and measurements. Interviews with the Director of Nursing and the Unit Manager confirmed that weekly wound monitoring was not performed as required. Facility policy mandates completion of weekly pressure ulcer documentation immediately after skin rounds, but this was not followed for the resident in question, who had an unstageable pressure ulcer on the right heel.