Failure to Assess and Document Pressure Ulcer Care and Implement RD Recommendations
Penalty
Summary
Facility staff failed to provide necessary treatment and services consistent with professional standards of practice to promote healing of existing pressure ulcers for two residents who were admitted with pressure injuries. For one resident with moderate cognitive impairment and a stage 2 sacral pressure ulcer present on admission, the admission skin assessment documented only basic wound information (location, stage, and measurements) and did not include a full wound assessment as required by facility policy, such as drainage, tissue type, wound edges, or surrounding tissue. After admission, the electronic medical record contained no documentation that staff completed any skin assessments from the day after admission through several weeks later, despite the resident being at risk for pressure ulcers and having documented pressure ulcer care needs. The same resident had a hospital skin care team recommendation for specific topical products to multiple areas and an RD progress note recommending a wound-healing protein supplement twice daily, but there was no corresponding physician order for the nutritional supplement on the POS. The POS did contain multiple wound care orders for the sacral area, left inner thigh abrasion, and right buttock over the course of the stay, including use of Triad, calcium alginate, Duoderm, and Vashe wet-to-dry dressings. However, the TAR showed missing documentation of ordered wound treatments to the sacral area and left inner thigh on multiple dates, and the progress notes did not document that these treatments were missed or refused. Interviews with the DON and Administrator confirmed that nurses were expected to complete weekly skin assessments, document full wound assessments per policy, and implement and document RD recommendations, but this did not occur. For the second resident, who was re-admitted with severe cognitive impairment, incontinence, and a stage 3 pressure ulcer present on admission, the care plan directed staff to administer treatments as ordered and monitor for effectiveness. The POS included orders to apply border gauze to the left heel each dayshift and Triad paste to the buttocks/right sacral area every shift. Review of the TAR showed that staff did not document completion of these ordered treatments to the left heel and buttocks/right sacral area on several dates. As with the first resident, the progress notes contained no documentation explaining the missed treatments or indicating that the resident refused them. The DON stated that nurses were responsible for completing wound treatments as ordered and documenting them on the TAR, but could not explain why the treatments were not documented as completed.
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