Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards of practice for one resident who was at risk for pressure ulcers and had a history of dementia and a right lower leg fracture. Upon admission, the resident had no open skin areas, but over the course of their stay, developed multiple facility-acquired pressure ulcers. The facility did not complete a baseline care plan addressing the resident's skin or risk for pressure ulcers upon admission, and subsequent care plans and assessments contained inaccurate or missing information regarding the presence, staging, and description of the pressure ulcers. There were numerous missing weekly wound assessments for each of the resident's pressure ulcers, and the facility did not document evaluation of the development of these ulcers to determine causative factors or assess the effectiveness of interventions. Additionally, the facility failed to obtain or request the resident's wound clinic notes in a timely manner, and the discharge MDS inaccurately reported the number of pressure ulcers present at discharge. Interviews with multiple staff members revealed that none could recall the resident in question, and facility leadership confirmed the inaccuracies and missing documentation related to the resident's pressure ulcers. These failures resulted in the resident being discharged with multiple unassessed and inaccurately documented pressure ulcers.