Failure to Document Pressure Ulcer Assessment and Treatment in Clinical Record
Penalty
Summary
The facility failed to ensure that the clinical record accurately reflected the assessment and treatment of a pressure ulcer for one resident. According to facility policy, nursing staff are required to assess and document significant risk factors for pressure ulcers, as well as provide a full assessment of any pressure sores, including location, stage, measurements, and the presence of exudates or necrotic tissue. For a resident with a physician order for wound care to the buttocks, the clinical record showed an initial skin observation assessment noting an open area on the coccyx. However, subsequent facility documentation did not include required wound assessments, measurements, or treatment interventions. Instead, the facility relied solely on hospice documentation for monitoring and treatment of the pressure ulcer, without entering this information into the resident's clinical record. The DON confirmed that the facility did not document the wound and treatments in the clinical record, as required by policy.