Failure to Assess and Document Pressure Injury
Penalty
Summary
The facility failed to ensure ongoing assessment, monitoring, and documentation of an identified pressure injury for one resident. Upon discovery of an open area on the resident's coccyx, there was no documentation of an initial wound assessment, including measurements, wound type, tissue type, drainage details, or peri-wound description. Additionally, there was no evidence that the resident's provider or representative was notified of the new wound, nor were any new treatment orders obtained. The resident's care plan, while indicating risk for pressure injuries, did not reflect the presence of an active pressure injury or update interventions accordingly. Review of the electronic health record and treatment administration record showed that the only ongoing intervention was the application of lanolin cream, with no changes made after the wound was identified. Weekly skin observation notes lacked essential wound details, and staff were unable to provide documentation of required assessments or notifications. The facility's policy required prompt reporting, assessment, and care plan updates for pressure injuries, but these actions were not completed for the resident in question.