Failure to Accurately Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess and document pressure ulcers for two residents, as required by facility policy and nationally accepted guidelines. For one resident with a history of coronary artery disease, hypertension, and acute osteomyelitis of the right foot and ankle, there were no documented wound measurements for the right foot amputation site from late May through late June, despite physician orders for wound vac application and care. The Director of Nursing confirmed the absence of weekly wound measurements for this site. Another resident, admitted with diagnoses including surgical aftercare of the digestive system, peritonitis, and alcoholic cirrhosis of the liver, had a pressure ulcer on the coccyx. The clinical admission assessment and subsequent clinical records from late April through late June showed no documented measurements of the pressure ulcer, despite physician orders for daily wound care. The Assistant Director of Nursing confirmed that the facility did not accurately assess pressure ulcers for these two residents as required.