Failure to Properly Assess and Treat Multiple Pressure Ulcers
Penalty
Summary
The facility failed to properly assess and treat pressure ulcers for a resident with multiple complex medical diagnoses, including multiple sclerosis, quadriplegia, and myelodysplastic syndrome. Medical record review showed that the resident had a Stage IV pressure ulcer present upon admission, and weekly wound assessments were being conducted. However, the documentation only included measurements for the entire affected area and did not provide separate descriptions or measurements for each distinct pressure ulcer. During wound care observation, two separate wounds were identified on the resident's right buttock/sacrum area, but only one wound received the prescribed treatment. The LPN performing the care stated that the documentation did not indicate a second pressure ulcer, so treatment was only applied to one wound. Further interviews confirmed that the wound care clinician was aware of two distinct pressure ulcers but had only documented the area as a whole, not individually. The facility's policy required individualized treatment and assessment for each pressure injury, but this was not followed. As a result, one of the resident's pressure ulcers did not receive the ordered treatment, and the documentation failed to accurately reflect the resident's wound status. This deficiency was identified during a complaint investigation and affected one resident reviewed for wound care.