Failure to Document Ongoing Pressure Ulcer Assessments and Treatment Progress
Penalty
Summary
The deficiency involves the facility’s failure to document ongoing assessment and treatment progress for pressure ulcers for one resident with multiple risk factors and existing wounds. The resident was re-admitted from the hospital with an open area on the coccyx and an open area on the left thigh, and had diagnoses including dislocation of an internal left hip prosthesis, age-related osteoporosis, and unspecified protein-calorie malnutrition. A care plan identified a stage 3 pressure ulcer to the coccyx and a stage 2 pressure ulcer to the left thigh, with interventions directing staff to follow facility protocols for treatment and to monitor and document the location, size, and treatment of the skin injuries. A 5-day Medicare MDS documented severe cognitive deficit and unhealed pressure ulcers. Despite these findings and the facility’s policy requiring weekly skin assessments and weekly documentation of the effectiveness of pressure injury prevention techniques, the medical record lacked any weekly skin assessments. A facility wound report later showed that the last documented wound assessments for the coccyx and left thigh pressure ulcers were on the date of admission, with no subsequent assessments recorded until an unstageable pressure wound was assessed on a later date. The wound NP reported that she had been seeing the resident for only a couple of weeks, did not have access to the EMR, and therefore could not review or document the resident’s wound history or current care in the system. She stated that when she began seeing the resident, she did not find ulcerations on the coccyx or left knee and had only seen a heel wound, but could not determine prior wounds or treatments due to lack of documentation. The Regional Clinical Consultant confirmed that the NP did not have EMR access, and the Administrator acknowledged there was no wound nurse on staff, that the NP came weekly with a staff nurse, and that hall nurses were responsible for wound treatments, while she was unfamiliar with where wound notes were located in the EMR. These circumstances resulted in incomplete and missing documentation of the resident’s pressure ulcer assessments and treatment progress.
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