Failure to Perform Weekly Pressure Ulcer Reassessment and Documentation
Penalty
Summary
The facility failed to ensure that a resident with multiple pressure ulcers received care in accordance with professional standards of practice. The resident, who was admitted with several Stage 4 and unstageable pressure ulcers and had severely impaired cognitive skills, was dependent on staff for all activities of daily living. The baseline care plan identified impaired skin integrity and required treatment as ordered, with monitoring for signs of infection. However, the weekly reassessment and documentation of the resident's pressure ulcers, including type, location, measurement, and description, were not completed as required. Specifically, the treatment nurse did not reassess or document the pressure ulcers on a scheduled weekly basis, as confirmed during an interview and record review. The facility's treatment nurse job description required maintaining and updating a pressure ulcer profile weekly, but did not specify reviewing and revising the care plan for accurate wound care guidance. Additionally, the facility's policy on pressure ulcers did not require scheduled weekly reassessment to determine progression. This lack of consistent and thorough reassessment and documentation increased the risk of the resident's pressure ulcers worsening or receiving inappropriate or delayed treatment, as the status and progression of the wounds were not adequately monitored.