Failure to Monitor and Document Venous Ulcers Between Vascular Clinic Visits
Penalty
Summary
The facility failed to monitor and document vascular wounds for a resident with venous ulcers to both lower extremities, contrary to its own wound care policy and the resident’s comprehensive care plan. The facility’s Skin Integrity, Wound, Ulcer Assessment Prevention Treatment Documentation Policy required that wounds be measured in three dimensions (length, width, depth) upon identification and routinely thereafter, with documentation on a wound progress assessment form for all impaired skin integrity issues. The resident’s MDS showed the resident was cognitively intact, dependent for most ADLs, and had two venous and/or arterial wounds. The comprehensive care plan identified venous ulcers on both lower extremities, with the right worse than the left, and included interventions to monitor and document the location, size, and treatment of any skin injury or change when noted and then weekly until healed, and to report abnormalities or failure to heal to the physician. Despite these requirements, record review of the resident’s EHR assessments and progress notes over several months revealed no wound evaluations with descriptions or measurements of the venous ulcers. Documents from the vascular clinic visits contained treatment orders and follow-up dates but did not include wound descriptions or measurements. The resident reported going to a vascular clinic for management of venous ulcers, and observation showed both lower legs wrapped with gauze bandages from ankles to knees. The ADON stated the resident’s venous ulcers were measured and assessed at the vascular clinic and confirmed that this was why there were no wound evaluations in the facility’s EHR. The DON confirmed the facility had not obtained wound descriptions or measurements from the vascular clinic visits, and the Director of Compliance confirmed the venous ulcers should have been evaluated weekly and monitored between clinic appointments, but staff were unable to provide additional wound information before survey exit.
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