Failure to Document and Assess Wound Care and Skin Integrity
Penalty
Summary
Facility staff failed to maintain professional standards of care by not documenting the administration of wound treatments as ordered by physicians, not completing wound assessments, and not performing weekly skin assessments for multiple residents with wounds. Specifically, for one resident, there were repeated omissions in documenting wound treatments on the Treatment Administration Record (TAR) for various wounds, including a right leg below-knee amputation, buttocks, and left heel. The records also lacked full assessments of these wounds on several occasions, despite ongoing physician orders for wound care. The facility's own policy required comprehensive wound assessments and weekly skin evaluations, which were not consistently performed or documented. Another resident, who was assessed as having severe cognitive impairment and receiving hospice care, did not have documented weekly skin assessments for multiple periods, even though the wounds were being assessed by external providers such as a wound physician and hospice nurse. However, facility nurses were still expected to complete and document these assessments, as confirmed by staff interviews. Similarly, a third resident with severe cognitive impairment and at risk for pressure ulcers had a stage two pressure ulcer identified, but the documentation did not include a full wound assessment or regular weekly skin assessments as required. Interviews with facility staff, including the acting Director of Nursing (DON) and other registered nurses, confirmed that nurses were responsible for completing and documenting wound treatments and weekly skin assessments. Staff acknowledged that missing documentation likely indicated that treatments were not administered, and that full wound assessments were not being completed as expected. The administrator and acting DON were aware of these documentation lapses and the failure to adhere to the facility's protocols for wound care and skin assessments.