Failure to Obtain Orders and Provide Timely Pressure Ulcer Care on Admission
Penalty
Summary
The facility failed to obtain physician orders and provide timely wound care treatment for two mid-spine pressure ulcers present on admission for one resident. Upon admission, the nurse responsible for the initial skin assessment did not document the presence of the spinal wounds, despite observing a dressing on the resident's spine. The nurse, who was new to the facility, was unsure about wound care standing orders and did not notify anyone to obtain wound care orders on the day of admission or the following day. As a result, no wound care orders were in place for the resident's spinal wounds for the first two days after admission. The resident, who had a history of joint replacement surgery and dementia, was identified as being at risk for skin breakdown and required significant assistance with activities of daily living. The wounds were only formally identified and addressed by the wound care nurse on the third day after admission, at which point wound care orders were initiated and treatment began. Documentation confirmed that wound care was not provided or recorded for the spinal wounds during the initial period after admission, and the physician was not notified in a timely manner regarding the need for wound care orders.