Failure to Perform and Document Weekly Pressure Ulcer Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide and document necessary pressure ulcer treatment and services consistent with professional standards and facility policy for a resident with multiple pressure injuries. Facility policy required nurses to complete and document a full assessment of pressure sores, including location, stage, length, width, depth, and presence of exudate or necrotic tissue. The resident’s diagnoses included a pressure-induced deep tissue injury to the left heel, a stage 4 pressure ulcer to the sacrum, and paraplegia. Physician orders directed specific wound care to the sacral pressure ulcer and required a weekly body audit every Monday. However, Weekly Body Audit forms completed on three dates in December did not document the resident’s existing pressure ulcers in the section for alterations in skin integrity. Further review of the clinical record, including progress notes, showed no documented wound assessments with descriptions or measurements between mid-December and late December, when the resident was transferred to the hospital. After the resident’s return from the hospital on January 1, a readmission evaluation noted pressure ulcers on the coccyx, right heel, and left heel, but left blank the sections for length, width, depth, stage, and additional observations/comments. There were no documented assessments with descriptions or measurements of these pressure ulcers between the readmission date and mid-January, when the resident was again transferred to the hospital. During interviews, the DON acknowledged that the resident had refused services from the in-house wound consultant but allowed nursing staff to perform ordered wound care, and confirmed that nursing staff should have completed and documented full wound assessments, including measurements, at least weekly for residents with pressure ulcers.
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