Failure to Timely Address and Treat New Pressure Ulcers
Penalty
Summary
The facility failed to address a newly developed pressure ulcer for a resident with significant medical conditions, including diabetes with polyneuropathy and hemiplegia following a stroke. The resident required substantial assistance with activities of daily living and repositioning. On discovery of open wounds and areas of concern on the resident's right buttock and heel, nursing staff documented the findings and applied dressings per nursing judgment, but did not notify the provider, obtain wound treatment orders, or document the interventions on the Treatment Administration Record (TAR) as required by facility policy. No progress notes or physician orders for wound care or pressure reduction modalities were entered for 20 days after the wounds were first identified. Multiple staff interviews revealed confusion and lack of clarity regarding responsibility for provider notification, order acquisition, and documentation. Some staff believed it was the responsibility of the wound nurse or Resident Care Manager, while others stated it was the responsibility of the nurse who identified the wound. The delay in obtaining appropriate wound care orders and implementing pressure reduction interventions resulted in the deterioration of the resident's wounds, with the wounds becoming unstageable by the time they were properly assessed and treated.