Failure to Assess and Document Pressure Wounds Prior to Becoming Unstageable
Penalty
Summary
The facility failed to properly assess, report, and document a resident's acquired pressure wounds before they became unstageable. The resident, who had multiple diagnoses including paraplegia, degenerative nervous system disease, and impaired mobility, was dependent on staff for activities of daily living, including toileting and transfers. Although the resident's admission Braden scale assessment indicated a risk for pressure injuries, the care plan and subsequent MDS did not reflect this risk, and no pressure injuries were documented during the look-back period. The resident's family member reported that the resident had a history of pressure injuries prior to admission, and was only informed weeks after admission that new, extensive wounds had developed. The wound care nurse identified a new sacral-coccyx wound during an assessment for a different healed wound, noting it was full-thickness but did not classify the wound type or document the tissue present, as she was waiting for the wound physician's assessment. The wound was not reported by staff prior to this identification, despite facility policy requiring daily skin observation and prompt reporting of abnormalities. The wound physician later assessed the resident and found both the sacral wound and a new right heel wound to be unstageable, with the sacral wound containing 40% necrotic tissue and the heel wound presenting as a deep tissue injury with a blood-filled blister. Documentation showed that the resident's comprehensive care plan was not updated to reflect the risk for skin breakdown until after the wounds were identified. Scheduled weekly skin assessments were not consistently documented, with the last recorded assessment occurring a week before the wounds were discovered. Facility policy required immediate assessment and documentation of any skin breakdown, including detailed wound descriptions, but these steps were not followed prior to the wounds becoming unstageable.