Failure to Complete Wound Measurements for Ongoing Assessment
Penalty
Summary
The facility failed to ensure that wound measurements were completed for ongoing assessment of a resident's diabetic foot ulcer. Medical record review showed that the resident, who had multiple diagnoses including diabetes mellitus, end stage renal disease, and dependence on renal dialysis, was admitted with a diabetic foot ulcer and had a physician's order for daily wound care. The care plan included interventions to complete wound treatment as prescribed. However, review of the skin and wound assessments from mid-June through late July revealed that no measurements of the diabetic wound were documented during this period. An interview with a registered nurse confirmed that the resident's wound was not measured between the specified dates. The facility's policy on wound treatment management required ongoing assessment of wounds, including monitoring the effectiveness of treatments. The lack of wound measurements was not in accordance with the facility's policy and current wound standards of practice, as ongoing assessment is necessary to monitor healing and determine if modifications to treatment are needed.