Failure to Perform and Document Comprehensive Wound Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, comprehensive assessment and monitoring of a resident’s lower extremity vascular wounds and to implement necessary practices to prevent worsening skin breakdown. The resident was admitted with dementia and peripheral vascular disease and had ongoing skin integrity issues related to vascular wounds on both lower extremities. An Annual MDS showed the resident was cognitively moderately impaired and required substantial/maximal assistance with mobility-related ADLs and used a wheelchair for mobility. Progress notes showed that from late October through late January, wound documentation for the resident’s left lower extremity was repetitive and lacked comprehensive assessment details. Entries on October 30 and November 7 documented a left lower extremity wound partially covered with slough, scant serous drainage, no infection, and stated wounds were improving with a directive to continue treatment, but did not include measurements or staging. On December 24, a new treatment order for the left shin wound was documented, including cleansing with antiseptic spray and application of Silvadene, with instructions to document the wound condition daily. Subsequent notes on January 6 and January 14 described five open areas with scattered scabs and scant serous drainage without signs of infection, but again did not include measurements or staging. Further progress notes dated January 15, 20, 22, and 27 repeated essentially identical descriptions of the left shin wound as vascular in appearance with five open areas, scattered scabs, pink granulation tissue, scant serous drainage, and no signs of infection, without additional or updated assessment information. The clinical record lacked documentation of required wound measurements, staging, or complete weekly assessments between October and early February, despite facility policy requiring assessment and documentation of location, stage, length, width, depth, and presence of exudate or necrotic tissue. Interviews with the NHA and the designated wound nurse confirmed that an outside wound management provider performed full-body skin assessments on all residents on February 2, and the wound nurse acknowledged that weekly full wound assessments with all required elements were expected but had not been fully documented for this resident’s venous ulcer prior to that date. The facility was unable to provide documentation that an RN completed timely and comprehensive wound assessments for the resident’s venous ulcer before February 2.
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