Failure to Provide and Document Pressure Ulcer Care and Skin Assessments
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents. For one resident with significant medical conditions, including peripheral vascular disease, hemiplegia, and cognitive communication deficit, staff did not complete daily wound care as ordered. Documentation in the Treatment Administration Record (TAR) showed that wound care treatments for both sacral and left lower extremity pressure ulcers were not consistently documented as completed on numerous days across July and August. The Wound Care Physician and facility leadership confirmed that if treatments were not marked as completed on the TAR, it indicated they were not performed, although they believed the care may have been provided but not documented. The resident was on hospice care, and the focus was on comfort, but the expectation remained that wound care orders would be followed and documented. Additionally, the facility failed to ensure that four residents identified as at risk for pressure ulcers received weekly skin assessments as ordered. Review of medical records and electronic Physician Order Sheets revealed that weekly skin assessments were missed on multiple occasions for these residents. The Director of Nursing (DON) stated that weekly skin assessments should be completed for all residents, regardless of hospice status, and that these assessments are typically performed by a nurse or wound nurse. The DON was unaware that these assessments had not been completed during the specified months and attributed the missed assessments to the departure of the wound nurse during that period. Interviews with facility leadership, including the Administrator and DON, confirmed that they expected nursing staff to follow physician orders and document completion of treatments and assessments. They were not aware of the missing documentation until it was brought to their attention during the survey. The lack of documentation for wound care and skin assessments was acknowledged as a failure to follow established protocols and physician orders, with the potential to negatively impact resident care and wound healing.