Failure to Perform and Document Required Pressure Ulcer Assessments
Penalty
Summary
The facility failed to ensure that a resident with a pressure wound received proper assessment and monitoring, as required by facility policy. Upon admission, the resident, who was cognitively intact and at risk for developing pressure wounds, was not given a head-to-toe skin assessment or a Braden Score evaluation. The resident was admitted with dermatitis, an open area on the right inner thigh, and a pressure ulcer on the right heel. Despite physician orders and facility policy mandating weekly skin assessments and documentation, there was no admission skin assessment or Braden Score completed, and documentation of weekly wound assessments was inconsistent and incomplete. Progress notes and treatment records revealed that the resident developed a dark, soft area on the right heel, which was initially not open but later progressed to an open wound with slough and eschar. The wound was treated according to orders, but there was a lack of accurate and timely documentation regarding the wound's progression. The skin assessment data form completed on one occasion was inaccurate, failing to note the heel wound, and there were no further completed skin assessment forms or detailed documentation of the wound's condition after it opened. Interviews with facility staff, including the LPN, Nurse Manager, Wound Nurse, and Director of Nursing, confirmed that required assessments and documentation were not performed as expected. Staff acknowledged that weekly skin assessments, progress notes, and accurate documentation of wound condition were not consistently completed. The Wound Nurse was not aware of the heel wound until notified by staff days after admission, and the resident was not seen by the Wound Nurse Practitioner until several days after the wound opened. The lack of proper assessment and documentation led to a failure in providing appropriate pressure ulcer care and prevention for the resident.