Failure to Accurately Assess and Stage Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess and document pressure ulcers, including the type and staging of wounds, for two residents with significant medical histories and skin integrity issues. For one resident with multiple sclerosis, depression, and incontinence, records showed a history of pressure ulcers and high risk for further skin breakdown. Despite ongoing documentation of open areas, maceration, and the presence of eschar and slough on the buttocks, wound assessments inconsistently identified the type and stage of the wounds. Observations revealed large, darkened, and macerated areas with open wounds, but the Director of Nursing (DON) was unable to provide accurate staging during the survey. Another resident, also with multiple sclerosis and a history of chronic osteomyelitis and diabetes, was documented as having a stage IV pressure ulcer on admission. Wound management reports and progress notes described ongoing issues with open wounds, granulation tissue, slough, and drainage, but the wounds were often labeled as "unspecified ulcers" without clear identification of type or stage. During interviews, the DON stated that wound types were recorded based on provider input and did not provide further clarification or accurate staging according to CMS guidelines. Facility policy required comprehensive wound documentation, including type, assessment data, and changes in condition, at least weekly. However, the records reviewed showed inconsistent and incomplete documentation regarding wound type and staging, as well as discrepancies between observed wound conditions and what was recorded. These actions and inactions led to a deficiency in the facility's assessment and documentation practices for pressure ulcers.