Failure to Identify and Document Pressure Injury on Admission
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to identify and document a deep tissue injury (DTI) on a resident's left heel upon readmission from the hospital. The resident, an elderly female with a history of cerebral infarction, type 2 diabetes, congestive heart failure, and anemia, was assessed as having intact cognition but required substantial to maximum assistance with mobility and transfers. The resident was at risk for pressure ulcers, as indicated in her care plan and assessments prior to hospitalization, but no skin issues were documented at the time of her readmission assessment by the RN. Upon review, it was found that the hospital discharge documentation noted a left heel pressure ulcer with skin intact, but the RN's clinical admission assessment stated there were no skin issues. The Wound Treatment Nurse later identified a DTI on the left heel during a follow-up assessment and obtained physician orders for treatment. Interviews revealed that the RN did not recognize or document the DTI during the initial assessment, and she stated uncertainty about identifying certain skin concerns, such as redness, as wounds. The RN also indicated that she would wait for the Wound Treatment Nurse to assess and would not contact the physician for treatment orders immediately. The Director of Nursing (DON) confirmed that the admitting nurse is responsible for completing a thorough head-to-toe skin assessment and documenting any findings on the clinical admission assessment, as well as notifying the treatment nurse. The DON stated that any skin concerns, even if not fully staged, should be documented and monitored from the date of admission. The facility's policy requires accurate clinical documentation to communicate the patient's health status and care needs. The failure to identify and document the DTI on admission resulted in a deficiency related to ensuring nursing staff have the appropriate competencies and skills to provide safe and effective care.