Failure to Perform Weekly Pressure Ulcer Reassessments
Penalty
Summary
A deficiency was identified when a resident with multiple pressure ulcers did not receive care in accordance with professional standards of practice. The resident, who was admitted with several Stage 4 and unstageable pressure ulcers, was found to have not had their pressure ulcers reassessed and documented on a weekly basis as required. The treatment nurse confirmed that a scheduled weekly reassessment and documentation of the pressure ulcers, including type, location, measurement, and description, was not completed for one week. This omission was acknowledged during an interview and record review, where the nurse stated that such reassessments are necessary to determine the status and progression of the ulcers and to make any needed adjustments to the wound care plan. The resident in question had significant medical issues, including severely impaired cognitive skills, total dependence on staff for daily activities, and a history of pressure ulcers present upon admission. The baseline care plan and Minimum Data Set (MDS) documented the presence of multiple pressure ulcers and the resident's high risk for developing additional ulcers. Despite these risk factors and the need for close monitoring, the required weekly wound assessments were not consistently performed or documented. Further review of facility policies and the treatment nurse's job description revealed gaps in guidance regarding the frequency and documentation of pressure ulcer reassessments. The facility's policy did not specify the need for scheduled weekly reassessments to monitor the progression of pressure ulcers, and the job description did not require the treatment nurse to review and revise the care plan as needed for accurate wound care guidance. These omissions contributed to the failure to provide care consistent with professional standards for pressure ulcer management.
Plan Of Correction
F-686 Corrective Action On 9/10/25, the DON gave the Treatment nurses an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. On 9/10/25, the DON gave the licensed nurse an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. Identification of Others On 9/11/25, the DON and Treatment nurse reviewed other residents' weekly wound assessments and documentation. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25, the DON gave the Treatment nurses an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. On 9/10/25, the DON gave the licensed nurse an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the DON and/or designee will review 5 random charts of residents with wounds and review if they have completed their weekly wound assessment; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.