Failure to Complete Comprehensive Pressure Ulcer Assessments
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice. For one resident with dementia, CHF, and diabetes, a pressure injury developed while in the facility. Although staff documented the presence of an open area and initiated wound care, a comprehensive assessment of the wound—including staging, wound bed, peri-wound, and other required characteristics—was not completed at the time of discovery. The care plan included interventions such as pressure-reducing devices and repositioning, but the initial assessment did not meet the facility's policy requirements for a comprehensive evaluation. Another resident, admitted with a history of cancer and at risk for pressure injuries, developed a pressure injury to the sacrum that was appropriately assessed prior to a hospital transfer. Upon readmission, the resident's pressure injury was not comprehensively assessed for three days, and the plan of care did not reflect the presence of an actual pressure injury or include comprehensive interventions. Documentation provided after readmission only included wound measurements and lacked detailed assessment of wound characteristics as required by facility policy. Interviews with nursing staff and the DON confirmed that comprehensive wound assessments were not completed as required for both residents. The facility's own policy mandates a thorough evaluation of wounds, including size, depth, location, stage, wound base, peri-wound, drainage, pain, and wound edges, but this was not followed. As a result, the facility did not ensure that residents with pressure injuries received the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing.