A recently appointed community nurse has been tasked to visit a diabetic patient at home who requires dressing on her pressure ulcer. This patient is overweight and bed bound.

For the past two weeks, every day, the nurse visited and the patient said she was okay, and that her dressing did not need to be changed. A safeguarding adult concern was raised with the Local Authority Safeguarding Team when the patient was admitted to hospital due to an infected and deteriorated grade 4 pressure ulcer. The documentation shows that the nurse had visited and the patient had refused treatment. The patient was deemed to have mental capacity to understand the treatment of her pressure ulcer.

Which one of the following must the nurse do to ensure good documentation and prevent the deterioration of the pressure ulcer?

Select all the answers you think are correct.