Failure to Provide Comprehensive Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide a comprehensive, resident-centered treatment plan for the prevention and management of pressure ulcers for a resident admitted with multiple complex medical conditions, including a stage III sacral pressure ulcer. Upon admission, the care plan noted the presence of pressure ulcers but did not document the size or provide a description of the wounds, and there were no treatment orders in place for the wounds to the right buttock or sacrum. The initial wound assessment and documentation were delayed until an outside wound doctor evaluated the resident several days after admission, at which point the stage III sacral ulcer was measured and described. Treatment orders for the sacral wound were not documented on the treatment administration record until several days after admission. Further review revealed that the care plan interventions included the use of an air mattress and regular repositioning, but the air mattress was set to a weight higher than the resident's current weight, as verified by staff and the DON. There was also a lack of documentation regarding the pressure ulcer to the right buttock, and only the sacral ulcer was identified by the wound doctor. The facility's wound and skin care policy required prompt initiation of a wound program, weekly measurements, and detailed documentation, which were not followed in this case.