Failure to Monitor and Document Pressure Ulcer Development
Penalty
Summary
The facility failed to adequately monitor and document the development and progression of pressure ulcers for one resident with significant risk factors, including dementia, morbid obesity, and limited mobility. The resident was dependent for transfers and mobility, had a history of surgical incision on the right leg, and was identified as at risk for pressure sore development according to the Braden Scale. Despite the presence of non-blanchable areas, blisters, and open wounds on the buttocks and coccyx, there was a lack of consistent wound measurements and documentation in the electronic health record. Orders for wound care were present, but wound monitoring and assessment were not consistently performed or recorded, and the physician was not notified of changes in the wound status. Staff interviews revealed that wound measurements had not been regularly taken, and the wounds were sometimes attributed to friction or shearing rather than pressure, leading to inconsistent documentation. The physician stated that they were not informed of any worsening of the wound beyond a stage-1 sore. The facility's policy required systematic monitoring and documentation of wounds, but this was not followed, as evidenced by missing wound notes and measurements. The deficiency was identified through observation, interview, and record review, confirming a failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.