Failure to Thoroughly Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to thoroughly assess and document the progression of pressure ulcers for a resident diagnosed with osteomyelitis of the sacrococcygeal region, including the sacrum and coccyx. The resident was admitted with pressure ulcers on the left gluteus and right heel, and physician orders directed specific wound care interventions, including the use of heel protectors, a low air loss mattress, and evaluation by a wound care specialist. However, skin assessments lacked complete documentation, such as wound characteristics and depth measurements. Notably, the gluteal pressure ulcer increased significantly in size, but the assessment did not include all required details, and there was no documentation that the physician was informed of this change. During wound care observations, staff performed cleaning and dressing changes but did not consistently measure or document the depth of the wounds as required. The facility's own guidelines specified that wound type, location, stage, measurements, undermining or tunneling, drainage, odor, and assessment of the wound bed and surrounding tissue should be recorded in the electronic medical record. Despite these requirements, documentation was incomplete, and there was a lack of evidence that the physician was notified of the worsening condition, contributing to the deficiency.