Inconsistent Wound Documentation and Communication for Hospice Resident
Penalty
Summary
The facility failed to maintain accurate and consistent wound documentation for a resident who was receiving hospice services. Upon admission, the resident had a red, non-blanchable area on the right outer ankle, which was initially documented as a suspected deep tissue injury (SDTI) and later as a Stage I pressure ulcer by facility staff. However, hospice documentation later identified the same wound as an unstageable pressure ulcer with significant eschar and necrotic tissue, indicating a deterioration that was not reflected in the facility's records. There was no evidence of additional wound assessments or updates in the facility's documentation after the initial assessments, despite the change in the wound's condition noted by hospice staff. Interviews with facility nursing staff revealed that they were not notified by hospice of any changes in the wound's status or given new orders for wound care. The facility's records did not show that the physician was notified of the wound's deterioration, nor were there any new or updated wound care orders documented. The facility's wound care policy required treatment based on the wound's location, stage, and drainage, but the lack of updated assessments and communication resulted in incomplete and inaccurate medical records for the resident. Additionally, the resident's guardian reported that the resident was discharged home with additional wounds to both feet, which were not documented in the facility's discharge assessment. Hospice staff also observed that preventative measures to avoid pressure ulcer deterioration may not have been consistently followed, as the resident was found sitting on her feet due to contractures. The inconsistency between facility and hospice documentation, lack of timely wound reassessment, and failure to update medical records contributed to the deficiency identified during the complaint investigation.