Failure to Document and Manage Pressure Ulcer Care
Penalty
Summary
The facility failed to consistently document and assess a resident's pressure ulcer upon admission and during their stay. Upon review, it was found that the resident was admitted with multiple diagnoses, including a right lower leg fracture and dementia, and was assessed as having a moderate risk for developing pressure ulcers. However, there was no documentation of the site and description of the existing pressure ulcer on the coccyx/buttocks at admission, and subsequent progress notes lacked detailed wound assessments, including measurements and descriptions as required by facility policy. Further review revealed that physician orders for wound care and pressure-relieving interventions, such as the use of a low-air-loss mattress and regular turning and positioning, were not consistently documented as being implemented. The care plan did not include interventions or tasks related to the use of a pressure-relieving mattress, despite recommendations from the wound care provider. Additionally, required bi-weekly skin observations and Braden scale assessments were either missing or inconsistently documented in the medical record for the three weeks following admission. Interviews with nursing staff and facility leadership confirmed lapses in documentation and assessment practices. Staff acknowledged that wounds were not always measured or described, and that documentation was sometimes missed. The facility's own policy required full assessment and documentation of pressure ulcers, including location, stage, and measurements, as well as examination of newly admitted residents for existing skin conditions, but these standards were not met in this case.