Failure to Provide Consistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate treatment and services to prevent and heal pressure ulcers for a resident with multiple complex medical conditions, including lymphedema, chronic kidney disease, and a history of infected wounds. Upon admission, the resident was noted to be bed bound with chronic wounds and pressure ulcers at the sacrum and right thigh. Medical documentation indicated the presence of a stage 3 pressure ulcer on the right thigh and a stage 2 ulcer on the sacrum, with wound therapy assessments and specific wound care orders in place. However, there were significant gaps in the documentation of wound assessments, including missing weekly skin assessments with measurements and wound characteristics, making it unclear whether the prescribed treatments were consistently performed or effective. Further review of the Treatment Administration Record (TAR) revealed blank entries on several dates, indicating that wound care may not have been administered as ordered. The Director of Nursing confirmed challenges with documentation and continuity of care due to turnover among wound care nurses and the use of multiple outside wound care teams. No wound assessments or measurements were found for an entire month, and the facility was unable to provide documentation to demonstrate ongoing evaluation or progress of the resident's wounds during that period.