Failure to Consistently Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to properly assess and document a coccyx pressure ulcer for one resident with a history of dementia and a urinary tract infection. The resident was admitted with a low pain score and later developed a stage 3 pressure ulcer in the sacral region. Review of facility records showed inconsistent and incomplete documentation of weekly wound assessments and skin evaluations, with several dates missing required wound descriptions and skin section entries. The Braden Scale assessment indicated the resident was at very high risk for pressure ulcers, yet the documentation did not consistently reflect thorough wound monitoring. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that weekly wound assessments, including staging and detailed wound descriptions, were expected but not always completed or documented as required. Facility policy specified that all wound assessment data should be recorded in the resident's medical record, but this was not consistently done. The lack of regular and complete wound assessment documentation had the potential to delay identification of infection or changes in the wound's condition.