Failure to Complete Required Weekly Pressure Ulcer Assessments
Penalty
Summary
A resident with severe cognitive impairment and a diagnosis of two stage 2 pressure ulcers did not receive the required weekly wound assessments with measurements as ordered by the physician and outlined in facility policy. The resident's treatment orders included daily wound observation and dressing changes, as well as weekly skin observation and wound measurements. However, review of the electronic health record and treatment administration records showed that no measurements of the right sacral wound were documented from early May to the end of May. The facility's wound nurse was on medical leave during this period, and although a contracted wound nurse visited the resident and performed some assessments, there were gaps in the documentation of wound measurements and descriptions. Interviews with staff confirmed that the required weekly wound assessments with measurements were not completed by facility RNs during the wound nurse's absence. The Director of Nursing acknowledged that assessments with measurements should have been performed weekly and that this did not occur between the specified dates. Facility policy required licensed nurses to record the location, measurements, and characteristics of any pressure ulcer at least weekly, but this standard was not met for the resident in question.