Failure to Prevent, Assess, and Document Pressure Ulcers
Penalty
Summary
The facility failed to ensure that pressure ulcers were properly documented, assessed, and managed according to professional standards and facility policy. A resident was admitted with no evidence of pressure ulcers, as confirmed by admission assessments and transfer documentation. Despite this, within nine days of admission, the resident developed both a stage 3 and a stage 4 pressure ulcer. There was no evidence of weekly skin assessments, and the initial wound assessment was not completed when the wounds were first identified. The care plan addressing the pressure injuries was not initiated until several days after the wounds were discovered, and there was a lack of documentation regarding family notification about the new wounds. Physician orders for wound care were not consistently implemented or documented. The electronic medical record showed no evidence of daily wound assessments or that wound care was provided as ordered. Documentation for interventions such as barrier cream application and turning/repositioning was frequently missing across multiple shifts, both before and after the wounds were identified. Interviews with staff, including the Unit Manager, DON, LPNs, and CNAs, confirmed that required documentation and care practices were not followed, and that if care was not documented, it was considered not done according to facility policy. Facility policies required comprehensive skin assessments upon admission, daily skin inspections, weekly risk assessments, and prompt care plan updates following changes in condition. These policies also mandated thorough documentation of wound care, skin condition, and family notification. The review of the resident's records and staff interviews revealed that these standards were not met, resulting in the development and inadequate management of two facility-acquired pressure ulcers.