Failure to Complete Weekly Wound Assessments for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to provide weekly wound assessments for two residents with pressure ulcers, as required by facility policy. For one resident with severe cognitive impairment and an unstageable pressure ulcer on the left heel, documentation showed gaps in weekly wound assessments, with no assessments completed during several multi-week periods. The resident's wound was discovered and documented, but subsequent assessments were not consistently performed or recorded on a weekly basis, as confirmed by both progress notes and hospice wound records. The Director of Nursing (DON) acknowledged that there should have been weekly wound assessments with measurements and descriptions, and that documentation was lacking during the identified periods. A second resident, also with severe cognitive impairment and a deep tissue injury to the right lateral heel, did not have weekly wound assessments documented for a period of time following the discovery of the wound. Staff interviews revealed inconsistent practices regarding the frequency of wound assessments, with some staff indicating that assessments depended on wound severity or dressing changes, rather than adhering to the weekly requirement. Facility policy specified that weekly measurements and assessments should be documented in the electronic health record, but this was not consistently followed for the residents in question.