Failure to Complete Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to ensure that a resident's deep tissue pressure injury (DTPI) to the left heel was assessed and documented weekly as required by facility policy and regulatory guidelines. The resident, who was admitted with multiple diagnoses including a pelvic fracture, diabetes with neuropathy and a foot ulcer, malnutrition, anemia, and peripheral vascular disease, had a care plan in place for impaired skin integrity related to the DTPI. The care plan required weekly skin assessments and documentation. However, review of the medical record showed that weekly wound assessments were not completed or documented on two specific dates, and there was no evidence that the resident was unavailable or refused assessment on those days. Interviews with staff revealed that the LPN responsible for weekly wound assessments was absent during the missed assessments, and no other staff documented that the wound was assessed in her absence. The interim DON confirmed the lack of documentation and was unable to provide any additional evidence that the required assessments were performed. Facility policy required that skin areas be measured and documented every seven days until resolved, but this was not followed for the resident's DTPI during the identified period.