Failure to Accurately Assess and Document Pressure Ulcers
Penalty
Summary
A resident with paraplegia was admitted with multiple stage three pressure ulcers and additional diagnoses including seborrheic dermatitis. The care plan included interventions such as administering treatments as ordered, use of a low air loss alternating pressure mattress, and weekly documentation of wound measurements and characteristics. Weekly skin assessments documented the size and condition of the wounds, with some wounds being measured together and noted to have moderate serosanguinous drainage. The care plan also required detailed weekly documentation of each area of skin breakdown. During an interview, the Unit Manager (UM) confirmed that wound rounds were conducted weekly with a nurse practitioner (NP), and that she was present during these rounds to record wound measurements. However, the UM admitted that on one occasion, she documented the same wound measurements from a previous assessment without remeasuring or reassessing the wounds herself. This failure to perform an independent assessment and accurate documentation of the resident's wounds constituted the deficiency identified in the report.