Failure to Document Comprehensive Wound Assessments and Immediate Care
Penalty
Summary
Facility staff failed to follow professional standards of care regarding assessment documentation for two residents who sustained skin injuries. In the first case, a resident with multiple medical conditions, including anemia, HIV, and chronic kidney disease, experienced a fall in a transportation van resulting in a skin tear to the left lower extremity. The only documentation provided was a brief mention of the injury's location and minimal details about swelling and pain. There was no description of the wound's size, appearance, bleeding status, or surrounding tissue, nor was there documentation of immediate care provided, such as cleansing or dressing application. Nursing notes for the date of the incident were absent, and while the physician was reportedly notified, there was no record of care orders or the physician's response. In the second case, another resident sustained a laceration to the right leg during a transfer with a mechanical lift and later a skin tear to the right flank after rolling off the bed. Initial documentation for both incidents lacked detailed wound assessments, including measurements, wound characteristics, and immediate interventions. The first detailed wound assessment was not recorded until the day after the injury, despite treatment orders being in place. Interviews with staff indicated that superficial wounds were not documented in detail, and the director of nursing confirmed that only treatment orders were entered for such injuries. Facility policies required comprehensive documentation and assessment following incidents, including wound characteristics such as location, size, exudate, pain, wound bed, and surrounding tissue appearance. These requirements were not met in the cases reviewed, as evidenced by the lack of descriptive assessments and immediate care documentation. The findings were discussed with facility leadership, and no additional information was provided to address the documentation deficiencies.