Failure to Timely Assess and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care and services consistent with professional standards to promote healing and prevent worsening of a pressure injury for a resident with significant medical conditions, including acute congestive heart failure and atrial flutter. Upon re-admission from a hospital stay, the resident's sacral area was documented as having intact, dry skin. However, an open area was identified on the left upper buttocks several days later, with documentation by an LPN noting the wound's size and characteristics. Despite this, there was no documented wound assessment or progress note completed by a Registered Nurse at the time of discovery, and the electronic wound assessment tracking form was not initiated until nine days after the wound was first identified. During this nine-day period, the resident was also transferred to and returned from the hospital, but no reassessment of the skin was documented upon return. The first comprehensive wound assessment was completed by a Registered Nurse only after this delay, at which point the wound had increased in size. Staff interviews confirmed the lack of documented wound assessments during this period, and the facility was unable to provide further information regarding the resident's wound care during the gap in documentation.