Failure to Provide Consistent Pressure Ulcer Care and Documentation
Penalty
Summary
A resident with a history of morbid obesity, edema, venous insufficiency, and hypothyroidism was found to have quarter-sized, healing stage II pressure ulcers on both buttocks during an observation. The resident reported having the ulcer for many months, and there was no pain or drainage noted at the time of observation. Despite the presence of these wounds, the resident's care plans did not address the risk for pressure ulcers or document a history of pressure ulcers. Physician orders for wound care were in place, but documentation in the medical record was inconsistent and incomplete, with missing weekly wound notes and lack of detailed wound assessments. Multiple staff interviews revealed confusion and lack of awareness regarding the resident's pressure ulcers. Some staff, including the nurse practitioner and LPNs, were unsure if the resident had a pressure ulcer, and there was disagreement about the staging and nature of the wounds. The wound log was incomplete, with missing measurements, staging, and inconsistent entries. The interdisciplinary team, including the registered dietitian and director of health and wellness, were unaware of the wound log and the resident's wound status. Additionally, there was no incident report or clear documentation of when the pressure ulcer was first identified, and weekly skin assessments were not consistently performed as required by facility policy. Facility policies required thorough documentation of skin assessments, regular wound monitoring, and interdisciplinary care planning for pressure ulcers. However, these procedures were not followed, as evidenced by the lack of detailed wound documentation, incomplete care plans, and inconsistent communication among staff. The failure to provide necessary care and services consistent with professional standards resulted in the potential for worsening or recurrence of pressure injuries for the resident.