Failure to Provide and Document Pressure Ulcer Care and Assessments
Penalty
Summary
Facility staff failed to provide ordered pressure ulcer treatments and appropriate documentation for two residents with pressure injuries. For one resident, there were multiple instances in January and February where prescribed wound care treatments, including cleansing, application of medicated ointments, and dressing changes, were not documented as completed in the electronic treatment administration record (eTAR). The clinical record did not contain explanations or documentation regarding these missed treatments. The resident's care plan noted multiple Stage 2 and Stage 3 pressure injuries present on admission, with contributing factors such as decreased mobility, incontinence, poor nutrition, and non-compliance with treatment. For another resident, staff did not consistently provide or document pressure injury treatments on several dates across July, August, and September. Additionally, there was a lack of weekly wound assessments, including measurements and descriptions of wound progress, for an unstageable pressure injury that later progressed to Stage 4. The care plan required weekly documentation of wound measurements and characteristics, but the clinical record showed gaps in this documentation. Interviews with staff revealed that changes in personnel, including the departure of a wound care nurse practitioner and an assistant director of nursing, contributed to lapses in wound tracking and assessment. Both residents had care plans that included interventions for pressure injury management, such as administering treatments as ordered and monitoring wound healing. However, the facility failed to ensure that treatments were consistently provided and documented, and that required wound assessments were completed as specified in the care plans. There was no evidence in the clinical records to account for the missed treatments or assessments on the identified dates.