Failure to Complete Comprehensive Pressure Injury Assessment on Admission
Penalty
Summary
A deficiency occurred when staff failed to implement professional standards of practice for pressure injury (PI) care and prevention for a resident admitted with an unstageable PI to the left heel. Upon admission, the resident had multiple diagnoses including hemiplegia, hemiparesis, MRSA infection, deep tissue damage to the left heel, diabetes mellitus, protein-calorie malnutrition, atrial fibrillation, chronic kidney disease, anxiety disorder, and depression. The resident was assessed as having intact cognition but required moderate to maximum assistance with activities of daily living and was identified as being at risk for pressure injuries. Despite the presence of a pressure injury on admission, staff did not complete a comprehensive PI assessment that included measurements and a detailed description of the wound. The initial clinical assessment only noted the existence of an unstageable PI without further specifics. The first documented wound assessment with measurements and description was not completed until several days after admission by the wound clinic. During an interview, the DON confirmed that there was no documented comprehensive admission assessment of the PI, despite acknowledging that such an assessment was expected.