SPOKANE, WA - A nursing home resident's deteriorating pressure injuries went undocumented on their admission assessment, creating potential gaps in necessary medical care and treatment planning.
Federal inspectors cited Touchmark on South Hill Nursing following an August 2024 complaint investigation that revealed assessment documentation failures affecting resident care coordination. The facility failed to accurately reflect a resident's wound status on their admission assessment, later modifying the documentation after the resident had already been discharged.
Documentation Discrepancies Discovered
The investigation centered on a resident who was admitted to the facility in February 2024 with a history of muscle weakness and heart problems. Hospital records from January 2024 showed the resident had multiple skin concerns before admission, including pressure injuries to both buttocks described as "purple areas" and injuries to both heels.
Despite clear hospital documentation of existing wounds, the facility's original admission assessment indicated the resident had no pressure injuries upon arrival. This assessment was later modified in April 2024 - three days after the resident's discharge - to show the resident actually arrived with four pressure injuries: two classified as unstageable and two as stage 3 wounds.
The modified assessment painted a dramatically different picture, documenting serious wounds that extended through multiple layers of skin and tissue. Stage 3 pressure injuries involve full thickness skin loss where fat or tissue becomes visible, representing significant medical conditions requiring specialized care protocols.
Medical Implications of Assessment Errors
Accurate wound documentation serves as the foundation for effective pressure injury prevention and treatment programs. When assessments fail to capture existing conditions, care teams cannot develop appropriate prevention strategies or treatment plans.
Pressure injuries develop when sustained pressure reduces blood flow to tissues, typically over bony prominences like heels, buttocks, and the tailbone. These wounds can progress rapidly without proper intervention, potentially advancing from superficial skin damage to deep tissue involvement affecting muscle, tendon, or bone.
The resident's wounds included deep tissue pressure injuries (DTPI) to both heels - a particularly concerning condition that may indicate severe underlying damage and can precede the development of more serious stage 3 or stage 4 injuries even with optimal treatment. DTI requires vigilant monitoring due to the potential for rapid deterioration.
Facility's Own Staff Acknowledge Problems
During the inspection, facility staff confirmed the documentation issues. The MDS Coordinator, who handles resident assessments, acknowledged that the admission assessment "did not accurately reflect Resident 4 as of the ARD [Assessment Reference Date]."
Staff members explained that pressure injuries can develop quickly when residents remain in one position for extended periods, preventing adequate oxygen flow to tissues. The resident's spouse noted that the resident spent most of their time in bed on their back rather than being repositioned regularly.
A registered nurse interviewed during the inspection acknowledged that the resident's wounds had worsened during their stay and that new wounds developed. The wound care nurse noted that different types of wounds require different treatment approaches, emphasizing the importance of accurate initial classification.
Assessment Standards and Requirements
Federal regulations require nursing homes to conduct comprehensive assessments that accurately reflect residents' conditions. The Minimum Data Set (MDS) serves as both a care planning tool and reimbursement mechanism, making accuracy essential for appropriate resource allocation.
Assessment data must be collected through multiple sources including nursing observations, therapy notes, provider documentation, and specialist evaluations. The assessment reference date represents a specific point in time, and all documentation must accurately reflect the resident's status during the seven-day observation period.
For pressure injuries specifically, facilities must determine staging based on findings from the first skin assessment conducted at or as close to admission as possible. Once an MDS assessment is completed and accepted, providers cannot modify it based on status changes that occur after the assessment period.
Industry Standards for Wound Documentation
Proper wound documentation should include detailed measurements, tissue descriptions, staging information, and assessment of factors like odor or patient discomfort. This level of detail enables healthcare teams to track healing progress and adjust treatment protocols as needed.
Facilities must also implement preventive measures for residents at risk of pressure injury development. Standard interventions include pressure-relieving devices, regular repositioning schedules, and specialized mattresses or seating surfaces.
The inspection findings highlight the critical importance of accurate admission assessments in ensuring residents receive appropriate care from their first day in the facility. When initial documentation fails to capture existing conditions, the resulting gaps can compromise both immediate treatment and long-term care planning.
Touchmark on South Hill Nursing must now develop corrective measures to ensure future assessments accurately reflect residents' conditions at the time of admission, protecting vulnerable individuals who depend on skilled nursing care for their health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Touchmark On South Hill Nursing from 2024-08-22 including all violations, facility responses, and corrective action plans.
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