Inaccurate Pressure Ulcer Measurement and Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to accurately measure and document pressure ulcer/injury (PU/I) wound dimensions for two residents, relying instead on automatically generated measurements from a photo device. One resident was admitted with an unstageable pressure ulcer on the sacrococcyx and diagnoses including osteomyelitis, spina bifida, and abnormal posture. An early progress note documented the sacrococcyx wound as 7.66 cm in length, 10.87 cm in width, 0 cm in depth, and 67.66 sq. cm in area, based on a photo taken by the treatment nurse. However, a subsequent surgical consult described the same wound, now characterized as a stage IV PU/I extending to bilateral buttocks, as 11.5 cm in length, 15.0 cm in width, 2.5 cm in depth, and 172.50 sq. cm in area, indicating that the earlier measurements did not reflect the actual wound size and depth. In interviews, the treatment nurse acknowledged that on the date of the initial photo for this resident, she did not manually measure the wound and instead accepted the device’s automatic readings, including a depth of 0 cm. She further stated that actual wound measurements were not obtained until the surgical consult several days later and that she relied on serial photos taken upon admission or the following day and then weekly to assess wound progress. The DON later confirmed that the treatment nurse documented this resident’s wound measurements incorrectly and did not manually verify or correct the automatically generated measurements. A second resident was admitted with diagnoses including acute kidney failure and a disorder of the skin and subcutaneous tissue and was identified on the MDS as having one or more unhealed PU/Is and being at risk for pressure ulcers. A progress note documented a sacral PU/I present on admission with measurements of 1.14 cm in length, 0.57 cm in width, 0 cm in depth, and 0.43 sq. cm in area, again based on a photo taken by the treatment nurse. A later surgical consult described a coccyx wound extending to the right and left buttock, staged as a stage II PU/I, with measurements of 7.0 cm in length, 3.0 cm in width, 0.1 cm in depth, and 21 sq. cm in area. The treatment nurse stated that the admitting nurse had only marked skin sites without measurements on arrival, and that she took photos and obtained measurements the following day using the device’s automatic readings, without manual measurement, despite knowing that the device’s measurements were sometimes inaccurate. The DON confirmed that the treatment nurse did not manually measure these PU/I sizes to correct the automatically generated measurements, contrary to facility policies requiring complete and accurate documentation of skin condition, including size and location of affected areas.
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