Failure to Perform and Document Weekly Skin Audits and Wound Measurements
Penalty
Summary
The facility failed to provide weekly body audits and wound measurements as required by its own policy and the resident’s care plan for a resident with an unstageable sacral pressure ulcer. The facility’s Pressure Injury/Wound/Skin Management policy dated 08/2016 required a licensed nurse to perform weekly body audits, wound measurements, and document findings in the medical record. The resident was admitted with an unstageable sacral pressure ulcer, documented on the admission record and baseline care plan, which identified impaired skin on the sacrum and directed staff to perform weekly skin checks. The admission MDS showed the resident had severe cognitive impairment with a BIMS score of 7/15 and one unstageable pressure ulcer present on admission. Record review showed only one Skin & Wound Evaluation dated on the admission date, documenting the sacral wound size and tissue characteristics, with no further documented skin checks or wound measurements for the remainder of the resident’s stay until discharge. Multiple LPNs, including the wound care nurse, reported in interviews that weekly skin audits were conducted and documented in the EHR, and that the wound nurse was responsible for weekly wound measurements with the wound physician. However, the wound care nurse acknowledged she did not know why this resident’s measurements were not documented, and the DON confirmed that the facility could not locate any wound documentation beyond the initial evaluation, despite her expectation that wounds be measured and documented weekly.
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