Failure to Consistently Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess and document the condition of a resident with chronic pressure ulcers. Nursing notes and skin assessments over an extended period showed that the resident's pressure ulcers were not consistently assessed on a weekly basis as required. The wound assessments that were present in the record lacked consistent documentation of wound characteristics, including measurements and descriptive details. There were several periods where the wounds increased in size, but the records contained limited or no wound measurements and insufficient descriptions of the wounds' characteristics during these times. According to the facility's own policy, pressure ulcer assessments should include daily monitoring and weekly documentation of wound type, location, staging, descriptive characteristics, measurements, progress toward healing, and signs of infection or complications. The policy also requires documentation of dressing status and interventions for pain. The Director of Nursing confirmed that weekly wound assessments, measurements, and thorough documentation of wound characteristics were not consistently performed, and acknowledged that the resident's wound had increased in size during this period.