Failure to Prevent and Manage Pressure Ulcer Due to Inadequate Assessment and Documentation
Penalty
Summary
A resident with multiple complex medical conditions, including acute stroke with craniotomy, paralysis, diabetes, chronic kidney disease, and severe cognitive loss, was admitted to the facility and identified as being at high risk for pressure ulcer development. The resident was dependent on staff for all activities of daily living and required two-person assistance for bed mobility, toileting, and transfers. Despite these risk factors, the facility failed to provide consistent and accurate skin care assessments, as no skin assessments were documented until several days after the initial identification of a wound. The first Braden skin assessment was completed late, and only two were performed during the resident's stay, both indicating high risk. Upon review, it was found that wound care orders and documentation were inconsistent and incomplete. Initial treatment orders lacked clear documentation of who ordered them and did not include wound descriptions or measurements. There was a significant delay in wound evaluation and assessment, with no physician documentation of the wound until eight days after its identification. Additionally, there were gaps in wound care treatment, with no ordered treatment for the sacral wound for a 12-day period, and multiple documented omissions of wound care treatments on several days. The facility's policy required weekly skin assessments, but these were not completed as required. Staff interviews revealed confusion and errors in documentation, with discrepancies between nursing notes regarding the presence of the wound. The LPN interviewed acknowledged that the pressure ulcer was not present on admission and occurred after the resident was admitted. The lack of timely and accurate assessments, incomplete documentation, and missed treatments contributed to the development and delayed management of an avoidable stage 3 sacral pressure ulcer for this resident.