Failure to Complete Weekly Comprehensive Wound Assessments
Penalty
Summary
The facility failed to complete comprehensive weekly wound assessments for one resident, as required by its own policies and procedures. The facility's wound care policy and skin care and wound management guidelines specify that wound assessments, including documentation of the wound's color, size, and drainage, must be performed at least weekly and whenever there is a change. Review of the resident's clinical records revealed that comprehensive wound assessments were missing for multiple consecutive weeks, despite physician orders to monitor the wound and provide daily care. The resident involved had multiple diagnoses, including diabetes, COPD, hyperlipidemia, and spinal stenosis, and was under care for a cancerous lesion requiring monitoring for infection and wound care. Staff interviews confirmed that the required weekly comprehensive wound assessments were not completed or documented for the resident over several weeks. The deficiency was acknowledged by both the LPN and RN responsible for wound care, as well as communicated to the Nursing Home Administrator.