Failure to Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to complete regular assessments and treatments for a pressure ulcer in one resident. Upon admission from the hospital, the resident had documented wounds to both heels, but the facility's initial assessments and weekly skin observations did not record these heel wounds. The Treatment Administration Record listed an order for skin prep to the bilateral heels, but there was no documentation that this treatment was provided from admission through discharge. Additionally, the clinical record lacked documentation of the presence or care of heel wounds until two weeks after admission, when a weekly skin observation finally noted a Stage 3 pressure ulcer on the right heel and a Stage 4 pressure ulcer on the left heel, without further description or measurements. The resident had a medical history including cellulitis of the left lower limb, heart failure, and obesity, and was identified as being at risk for pressure ulcers. Despite this, the facility did not document regular skin assessments or the completion of ordered treatments for the resident's heel wounds. The facility's policy required weekly review and documentation of skin assessments and pressure injury management, but this was not followed for the resident in question.