Failure to Assess and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer was properly assessed and provided with necessary treatment and services in accordance with professional standards of practice. The facility's policy requires prompt assessment and treatment of pressure injuries, including regular risk assessments, full body skin assessments, and documentation of findings in the medical record. However, for one resident who was admitted with multiple diagnoses including COPD, diabetes mellitus, and bipolar disorder, a new stage 3 pressure injury to the coccyx was identified, but the required weekly wound documentation was not completed from the time the wound was discovered. Additionally, the Braden Scale for Predicting Pressure Sore Risk, which is intended to be updated regularly and after significant changes in a resident's condition, had not been updated for this resident since several months prior to the identification of the pressure injury. The care plan for pressure ulcer development was also not updated in a timely manner to reflect the resident's current skin status. These lapses were confirmed by both the DON and the NHA during interviews, who acknowledged the lack of updated assessments and documentation. The deficiency was identified through review of facility policies, clinical records, and staff interviews, which revealed that the facility did not follow its own protocols for pressure injury prevention and management. The absence of timely wound documentation, risk reassessment, and care plan updates for the resident with a stage 3 pressure injury constituted a failure to provide care consistent with professional standards and the facility's stated procedures.
Plan Of Correction
Resident 8 was given a skin assessment during survey week. All residents with newly reported skin issues were reviewed to make sure they have the weekly skin notes. The Director of Nursing or designee will educate Nursing Administration staff on proper skin issue documentation. The Director of Nursing or designee will audit reports of new skin issues for skin assessments weekly, three times, and monthly, two times. Results will be turned into the monthly Quality Assurance meeting.