Failure to Assess and Treat Pressure Ulcer Upon Admission
Penalty
Summary
The facility failed to fully assess and document a pressure ulcer for a resident upon admission, as well as to obtain timely treatment orders and perform required ongoing assessments. The resident, who was admitted with multiple significant diagnoses including gangrene, diabetes, muscle wasting, and a recent above-the-knee amputation, was identified as high risk for pressure ulcers. Upon admission, an open area on the sacrum was noted, and the care plan documented a stage three pressure injury to the coccyx. However, there was no completed skin inspection assessment at admission, and no initial treatment orders were obtained for the pressure ulcer until 14 days after admission, when a nurse practitioner evaluated the wound and provided treatment recommendations. Additionally, the facility did not perform daily skin checks or provide weekly documentation assessments for the pressure ulcer as required by policy. Although weekly skin inspections were signed off on the Treatment Administration Record, there was no corresponding documentation in the medical record regarding the status of the pressure ulcer prior to the late treatment order. The Director of Nursing and Administrator confirmed these omissions, acknowledging the lack of assessment, documentation, and timely intervention for the resident's pressure ulcer.