Failure to Timely Assess and Document Pressure Ulcer
Penalty
Summary
A deficiency was identified when the facility failed to ensure timely and accurate assessment and documentation of a pressure ulcer injury for a resident. The resident, who had a history of cancer, impaired mobility, and poor nutrition, was at risk for pressure ulcers and had interventions in place, including skin checks and protective devices. Despite these measures, a discolored area was found on the resident's right heel by a CNA, and an LPN assessed the area, took a photo, and notified the resident's daughter and the DON. However, there was no documentation of the skin impairment in the nursing notes or a wound assessment on the date it was first identified. Further review revealed that the LPN communicated with the DON about the wound, and the DON allegedly suggested waiting to see if the area resolved, which the LPN interpreted as a directive not to document the wound at that time. The LPN later documented the wound as being discovered after the resident returned from an appointment, following the DON's instructions to identify it as community-acquired. Interviews confirmed that the wound was present before the appointment, and the documentation did not accurately reflect the timeline of the wound's discovery and assessment. The facility's policy required that any observed skin alteration be reported, assessed, documented, and communicated to the physician and family. In this case, although the wound was reported and a treatment order was obtained, the required documentation and wound assessment were not completed when the wound was first identified. This failure to follow policy and accurately document the pressure ulcer affected the resident and had the potential to impact other residents identified as having pressure ulcers.