Failure to Accurately Document and Assess Pressure Ulcer
Penalty
Summary
The facility failed to assess and accurately document a resident's wound, specifically a coccyx wound, for one of three residents sampled for wound care. According to the facility's policy, licensed nurses are required to conduct and document weekly skin observations, including the status of any pressure injuries. The resident in question was admitted with multiple diagnoses, including acute kidney failure, muscle weakness, and acute pancreatitis, and was cognitively intact. Medical records showed an order for weekly skin assessments, and initial documentation noted an open area on the coccyx. However, subsequent weekly skin observations and progress notes failed to consistently address the presence or status of the coccyx wound, with several entries indicating no skin concerns despite the initial finding. There was no documentation indicating that the coccyx wound had healed, and later observations described a red blanchable area and scar tissue at the same location. The Director of Nursing confirmed that nurses should have been documenting the wound each week or providing evidence of healing. This lack of consistent and accurate documentation regarding the resident's wound status constituted a failure to follow facility policy and placed residents at risk.