Failure to Complete and Document Wound Assessments
Penalty
Summary
The facility failed to provide appropriate skin assessments and treatment in accordance with professional standards of practice for two residents. For one resident with multiple traumatic injuries and a surgical incision on the left upper extremity, staff did not assess or document the condition of the surgical site, nor did they document the removal of steri strips as ordered. There was no evidence of ongoing assessments of the surgical incision, despite a physician's order for dressing changes and a noted incident of partial dehiscence and bleeding at the site. For another resident with a history of chronic ulcer, diabetes, peripheral vascular disease, and recent amputation, staff did not complete a comprehensive wound assessment when a new wound was first identified. The initial documentation lacked details such as wound size, and there was a delay in completing a full assessment. The resident was later found to have a pressure ulcer on the left heel, but the facility did not have documentation of an initial assessment with measurements when the wound was first discovered.