Failure to Consistently Assess and Document Pressure Ulcers
Penalty
Summary
Facility staff failed to provide necessary care and services for two residents with pressure ulcers by not consistently assessing, measuring, and documenting the progression of their wounds as required by facility policy. For one resident with peripheral vascular disease and a right heel pressure ulcer, staff did not measure the ulcer or consistently document wound characteristics over a period of several months. For another resident with a sacral pressure ulcer present from admission until discharge, staff failed to measure the wound at least weekly, with multiple weeks lacking any recorded measurements. Interviews with nursing staff revealed a lack of clarity regarding responsibility and frequency for wound measurement and documentation. Some nurses were unsure of the required frequency for wound assessments, and there was inconsistency in understanding whether registered nurses or licensed practical nurses should perform these tasks. An administrative nurse confirmed that staff are expected to assess and measure pressure ulcers weekly, but acknowledged that this was not always being completed.