Failure to Provide and Document Pressure Ulcer Care per Standards of Practice
Penalty
Summary
The facility failed to provide pressure ulcer care according to standards of practice for two residents with existing pressure ulcers. Staff did not complete weekly skin assessments, failed to document accurate and complete wound assessments, and did not obtain or follow physician orders in a timely manner. For one resident, there were multiple instances where wound care was not documented as provided, and wound assessments lacked full descriptions of the wounds, including size and appearance. Orders for wound care were delayed, and not all identified wounds had corresponding treatment orders. The care plan did not specifically address all pressure ulcers present, and documentation of wound care was missing on several dates. Another resident with a history of coronary artery disease, high blood pressure, and diabetes was identified as having a stage 2 pressure ulcer to the sacrum. Staff did not consistently document wound care as ordered on multiple dates, despite having a physician's order for specific wound treatment. The care plan indicated a risk for impaired skin integrity and the presence of a pressure ulcer, but documentation gaps persisted in the treatment records. Interviews with nursing staff and facility leadership confirmed that weekly skin and wound assessments were not always completed as required, and that documentation of wound care was inconsistent. Staff acknowledged being behind on wound assessments and described a process where tasks for skin assessments were generated in the electronic medical record, but these were not always completed or documented. The Director of Nursing and Administrator both stated that wound care should be provided and documented as ordered, and that all wounds should be included in the care plan and updated regularly, but this was not consistently done.