Failure to Complete Comprehensive Pressure Ulcer Assessments on Admission
Penalty
Summary
The facility failed to comprehensively assess pressure ulcer wounds upon admission for two residents. For one resident with multiple complex medical diagnoses, including end stage renal disease, diabetes, and a history of sepsis and cellulitis, the admission assessment and subsequent skin assessments documented the presence of multiple wounds, such as pressure ulcers and necrotic lesions. However, these assessments did not include required measurements or detailed descriptions of the wounds, despite facility policy mandating full documentation and measurement of wounds upon admission. Another resident, also with significant medical conditions including end stage renal disease, congestive heart failure, and dementia, was admitted and readmitted multiple times. Upon readmission, the resident had documented pressure ulcers and arterial ulcers, but the nursing evaluation and weekly skin assessments failed to include measurements or adequate descriptions of the wounds. The wounds were not measured until later by a wound nurse practitioner, and even then, only one measurement was recorded for both wounds, rather than individual measurements as required. Interviews with the DON and review of facility policies confirmed that the required comprehensive skin and wound assessments, including measurements and detailed documentation, were not completed as per protocol for these residents. The facility's own policies specified that wound assessments must include type, stage, measurements, and wound bed description, but these elements were missing from the records reviewed.