Failure to Implement and Document Weekly Wound Assessments for Pressure Injuries
Penalty
Summary
A resident with a history of metabolic encephalopathy, hemiplegia, hemiparesis, and diabetes mellitus was admitted with a Stage 3 pressure injury on the sacrum and suspected deep tissue pressure injuries (SDTPI) on both heels. The care plan for these wounds required weekly assessments and documentation by the wound doctor (WMD) and treatment nurse (TN), including measurements of each wound and reporting of any changes to the medical doctor. The resident was identified as bedfast with limited mobility and a moderate risk for pressure sores, requiring significant assistance with daily activities. Despite these documented needs and care plan interventions, there was no evidence in the facility's records of weekly wound assessments or documentation by either the WMD or TN for the resident's pressure injuries. The TN admitted to forgetting to inform the WMD, resulting in missed weekly assessments on two occasions. The Director of Nursing (DON) confirmed that there was no documentation of initial or weekly wound assessments as required by the care plan. Facility policies required regular risk assessments, ongoing evaluation of skin conditions, and documentation of interventions and their effectiveness. However, these protocols were not followed, as the resident did not receive the required weekly wound evaluations and documentation, nor were the wounds reported to the WMD for evaluation and management as outlined in the care plan.