Failure to Provide Comprehensive Skin Assessments and Timely Wound Care
Penalty
Summary
The facility failed to provide comprehensive skin assessments consistent with professional standards of practice for a resident with significant medical conditions, including protein calorie malnutrition, Type 2 diabetes with chronic kidney disease, and generalized muscle weakness. The resident, who also had cognitive impairment, was under physician orders for weekly body audits and daily wound care for a sacral wound. Despite these orders, there were gaps in wound assessment and documentation, particularly between February 27 and March 12, and again on March 19, when the wound care nurse did not complete required assessments. Nursing and wound care documentation showed that the resident's sacral wound was initially identified and measured, but subsequent assessments were either incomplete or missing. Progress notes and skilled nursing evaluations repeatedly referenced the wound but deferred detailed assessment and measurement to the wound care nurse, who did not consistently document these evaluations. As a result, there was a lack of ongoing, comprehensive assessment of the wound's condition, including its size, tissue status, and signs of infection or inflammation. The deficiency was further evidenced when a significant deterioration in the wound was documented on March 21, with an increase in wound size and missing depth measurement. The resident was later hospitalized for acute kidney injury, and upon return, a third-party wound care consultation identified a deep, unstageable sacral pressure ulcer requiring debridement. The facility's failure to perform and document regular, comprehensive wound assessments led to a delay in identifying changes and promoting healing of the pressure ulcer.