Failure to Measure and Document Pressure Injury Size on Admission
Penalty
Summary
The deficiency involves the facility’s failure to follow its wound care policy requiring complete pressure injury assessments, including measurements, for a resident admitted with multiple pressure-related skin injuries. The resident’s EMR showed admission with diagnoses including rheumatoid arthritis, chronic kidney disease, congestive heart failure, pressure-induced deep tissue damage of the right buttock, and unstageable pressure ulcers of the sacral region and left buttock. The resident’s skin integrity care plan documented actual skin impairment related to sacral and bilateral buttock unstageable pressure ulcers and included an intervention to monitor and document the location, size, and treatment of skin injuries. Despite this, the admission/readmission nursing assessment and a Skin/Wound Evaluation completed within 24 hours of admission did not include measurements of the bilateral buttock pressure injuries. During interview, the wound nurse stated she assesses newly admitted residents for skin impairments within 24 hours of admission but acknowledged she did not measure this resident’s buttock pressure injuries and was unsure why. She further stated that sometimes she does not measure pressure injuries if she is unsure how to measure them or is concerned about measuring them as larger than they are, and may wait for the wound nurse practitioner to assess. The DON stated that the admitting nurse assesses and documents wounds and that the wound nurse then assesses within 24 hours, and she believed pressure injuries should be measured at the time of assessment. The DON also stated that without admission wound measurements, she could not determine if a wound had enlarged between admission and the wound nurse practitioner’s visit. The facility’s Wound Care Guidelines policy required wound assessment documentation to include, at a minimum, wound type, etiology, location, date, stage, and measurements (length, width, depth), along with wound bed, edges, exudate, undermining, tunneling, and wound-related pain, which was not followed for this resident’s bilateral buttock pressure injuries.
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