Failure to Document Assessments and Timely Wound Care Interventions
Penalty
Summary
Surveyors identified deficiencies related to the facility's failure to accurately document assessments and ensure residents received treatment and care in accordance with professional standards. For one resident, Nitroglycerin was administered on multiple occasions without documentation of symptoms or assessments prior to administration. Interviews with the DON and an LPN confirmed that any change in condition, such as chest pain, should be documented in the electronic medical record, and that all steps taken in response to unusual symptoms should be recorded. However, the medical record lacked this required documentation. Another resident was found to have inconsistencies in skin assessment documentation within 24 hours of readmission. The admitting nurse documented intact skin, while subsequent assessments by the wound care nurse and nurse practitioner identified a stage 3 pressure ulcer and Moisture Associated Skin Damage (MASD) on the left buttock. The wound care nurse later explained that there was a user error in documentation, resulting in inaccurate records. Additionally, there was no evidence that the facility notified the resident's primary care practitioner of the wound upon readmission or that wound care treatment was initiated at that time, despite recommendations from the nurse practitioner. Wound care orders were not implemented until several days after readmission. Review of the GNA flowsheet and interviews with staff revealed further discrepancies, as documentation indicated no skin impairment for several days, despite clinical notes to the contrary. The facility's process for admission and wound care assessment was described by staff, but the records showed that required assessments and timely interventions were not consistently completed or documented. The DON confirmed that the hospital discharge summary did not indicate a wound, yet the resident developed significant skin impairment shortly after readmission, with delayed initiation of appropriate wound care.