Failure to Timely Assess and Document New Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely assessment and accurate documentation of new wounds for a resident with multiple comorbidities, including chronic kidney disease, diabetes mellitus, and contractures. The resident was admitted with no skin breakdown noted on the last weekly skin evaluation, but there was a gap in weekly skin assessments from early to late in the month. During this period, shower sheets indicated intact skin until one entry noted skin was not intact, but did not specify the location or provide further documentation. An internal incident report, not included in the resident's medical record, documented that an agency LPN identified open wounds on both lower ankles, describing them as stage II or III pressure ulcers. The LPN notified hospice and applied dressings, but there was no corresponding wound assessment or progress note in the medical record for that date. Subsequent review revealed that a physician's order for wound care was issued, but there was still no documentation explaining the new order or a hospice nurse progress note for the relevant dates. The first wound evaluation in the medical record occurred two days after the initial discovery, confirming new stage III pressure ulcers acquired in-house. The facility's records, including the Matrix for Providers, failed to list these pressure ulcers, and interviews with staff confirmed confusion about whether the wounds were in-house or community acquired. Additionally, hospice staff visits and assessments were not documented in the resident's medical record or hospice binder, and the facility's wound care policy requiring documentation of changes and assessment data was not followed.