Failure to Monitor and Assess Pressure Ulcer on Admission
Penalty
Summary
A deficiency occurred when the facility failed to adequately monitor and assess a resident's Stage IV sacral pressure ulcer during her respite stay. The resident, who was admitted with multiple complex diagnoses including acute kidney failure, acute respiratory distress syndrome, bacteremia, congestive heart failure, and atrial fibrillation, was dependent for all activities of daily living and had intact cognition. Despite the presence of a severe pressure ulcer on admission, the medical record lacked any wound evaluations or measurements throughout her stay. Staff interviews confirmed that the facility did not measure or assess the resident's pressure ulcer as required. The resident's home health nurse reported that the wound worsened during the facility stay and subsequently required a wound vac, noting that the wound had been close to healing prior to admission. Facility policy required weekly monitoring and documentation of wounds, including measurements and detailed descriptions, but this was not completed for the resident in question.