Failure to Thoroughly Assess and Intervene for Pressure Injuries
Penalty
Summary
The facility failed to thoroughly assess and intervene to promote the healing of pressure injuries for a resident with multiple comorbidities, including a right femoral neck fracture, chronic kidney disease, severe malnutrition, and dementia. Upon admission, the resident was found to have a stage 2 pressure injury on the right elbow, redness to the coccyx, and discoloration to both heels. Orders were in place for wound management, heel protectors, pressure-relieving devices, and other supportive measures. Initial care plans and interventions were documented, but there were gaps in the ongoing assessment and documentation of the resident's pressure injuries. Throughout the resident's stay, documentation of wound assessments and measurements was inconsistent and incomplete. The wound management detail report only included the initial measurement of the right elbow pressure injury and lacked further assessments or documentation for the coccyx and heels. A spreadsheet maintained by the DON contained some wound measurements but was not part of the official clinical record and lacked comprehensive wound characteristics. There was also no documentation of a specific treatment order for the right elbow or coccyx pressure injuries, and the care plan for pressure injuries was not fully implemented until much later, despite the presence of multiple wounds. Interviews with nursing staff and the DON revealed that wound assessments were sometimes missed or not entered into the electronic medical record, and that some treatments were provided as routine nursing measures without physician orders or proper documentation. Weekly skin assessments were recorded as existing skin impairment, but no detailed follow-up or wound progression was documented. The facility's policy required ongoing documentation of all impaired skin integrity areas in the electronic medical record, but this was not consistently followed, leading to a deficiency in the assessment and management of the resident's pressure injuries.