Failure to Accurately Document and Assess Resident Wound Status
Penalty
Summary
A deficiency occurred when the facility failed to ensure that assessments accurately reflected a resident's status, specifically regarding the presence and documentation of a wound. The wound care nurse (WCN) did not accurately document an existing wound on the resident's weekly skin assessments after a new skin issue developed. The initial Minimum Data Set (MDS) assessment also failed to record the presence of a skin issue, despite hospital records at admission noting a pressure injury to the right heel. The WCN's documentation on weekly assessments was inconsistent, with some entries marked as 'existing wound' and others using an unlisted abbreviation or indicating no skin issues, even when a wound was present. Additionally, the WCN did not document a progress note until several days after admission and could not explain the delay or the lack of documentation for certain dates when she was present at work. The resident involved was a seventy-six-year-old woman with multiple comorbidities, including a recent hip replacement, cancer, diabetes, and a history of pressure injury. Upon admission, her hospital records indicated a right heel pressure injury, but this was not reflected in the facility's admission assessment or initial MDS. Over the following weeks, the resident developed worsening foot pain and a blister on her right heel, which eventually burst and became a significant wound. Despite ongoing complaints of pain and visible changes to the wound, documentation and assessment by nursing staff remained inconsistent. The WCN and other staff members provided varying accounts of the wound's progression and care, with some confusion over the timing and nature of assessments and interventions. Interviews with the resident, her family, and facility staff revealed that the resident's pain complaints were not consistently addressed, and wound care was not provided as frequently as ordered. The resident and her family reported that wound care was only performed once a week, and the wound was not regularly assessed or treated. The wound ultimately deteriorated, leading to hospitalization and amputation. The facility's skin assessment policy required thorough and timely documentation of skin conditions, but this was not followed in the resident's case, resulting in inaccurate records and delayed recognition and treatment of the wound.