Failure to Document Required Wound and Skin Assessments for Residents With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to complete and document required wound and skin assessments for two residents with pressure ulcers and impaired skin integrity. One resident had a care plan identifying high risk for pressure ulcers and multiple existing pressure ulcers on the sacrum, ischial areas, heels, ankle, gluteal folds, and foot, with instructions for weekly licensed nurse assessments and daily monitoring for infection and physician notification if wounds were not healing. Treatment Administration Records for this resident showed missing documentation for ordered daily foot checks and daily skin checks on multiple dates, and when edema and open areas were documented, there were no corresponding progress notes describing edema, open areas, treatment, or physician notification. Skin Observation Tools listed multiple pressure areas and other skin issues but lacked wound measurements or descriptive details. Wound clinic notes on two separate visits contained detailed measurements and descriptions, including staging, presence of fibrin, exposed bone, and tunneling, but these details were not mirrored by facility nursing documentation. During observed wound care, multiple wounds were measured and described, but the report does not show that such assessments were routinely documented by facility staff. The second resident had an undated care plan for impaired skin integrity and risk for injury related to dementia, with physician orders for wound care to the left lateral ankle, daily foot exams, weekly skin checks, and preventive measures for coccyx skin breakdown. A physician wound visit documented a left lateral ankle wound with specific measurements, moderate exudate, and erythema, but the electronic medical record contained no nursing skin assessments. An observed dressing change showed the wound was closed and the resident denied pain or issues at the site, yet there was still no documented nursing assessment in the record. The DON stated that staff do not write individualized wound documentation and instead only upload wound clinic notes, and acknowledged that nurses were not documenting on wounds as required. These practices were inconsistent with the facility’s Pressure/Skin Breakdown-Clinical Protocol, which requires nurses to assess and document a full skin assessment including location, stage, dimensions, exudate, necrotic tissue, signs of infection, and impact of comorbid conditions on wound healing.
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