Failure to Identify and Document All Wounds on Readmission
Penalty
Summary
The facility failed to accurately identify and document all wounds present on a resident's readmission from the hospital. Upon review of the resident's hospital discharge summary and history and physical, it was indicated that the resident had two pressure wounds: one on the sacrum and one on the right heel. However, during the facility's admission process, only the right heel wound was identified and documented by the admitting nurse. The sacral wound, which was noted in the hospital records as infected, was not assessed, documented, or communicated to the wound care provider upon the resident's return. Interviews with facility staff, including the DON, LVNs, and the wound care NP, confirmed that the admitting nurse did not complete a thorough head-to-toe skin assessment or review the hospital discharge summary in detail. As a result, the sacral wound was not recognized, and no treatment orders were initiated for it. The wound care nurse and NP were not made aware of the sacral wound, and the resident was not included in wound care rounds or assessments for that area. The facility's policies required a comprehensive admission evaluation, including documentation and measurement of all wounds, and obtaining treatment orders, but these procedures were not followed in this instance. The resident involved had multiple complex medical diagnoses, including type 2 diabetes, anemia, chronic atrial fibrillation, chronic kidney disease, heart failure, and pancytopenia, all of which increased the risk for skin breakdown and infection. Despite being at high risk and returning from the hospital with documented wounds, the facility's failure to identify and address all wounds led to a lack of assessment and treatment for the sacral wound following readmission.