Failure to Provide Timely and Accurate Pressure Ulcer Care
Penalty
Summary
A resident was admitted to the facility with a history of sepsis, type 2 diabetes, and an existing pressure injury on the right buttock. Upon admission, the resident was assessed as being at risk for pressure injuries, and hospital records indicated the presence of a pressure injury prior to arrival. Despite this, the facility did not complete a thorough or timely skin assessment, as the initial skin map failed to document any skin issues, and the wound evaluation did not accurately reflect all existing wounds. The care plan was updated to include interventions such as a pressure-relieving air mattress and turning/positioning, but it did not specifically address all identified wounds, including a pressure injury on the right hip. Orders for wound care were not obtained until several days after admission, and there was confusion among staff regarding the documentation and location of the wounds. The resident reported that wound care was not provided during their stay, and staff confirmed that no wound care was administered due to the lack of timely physician orders. Interviews with facility leadership and nursing staff revealed that the required skin assessments were not completed within the expected timeframe, and there was a lack of clarity regarding the number and location of the resident's pressure injuries. The facility was unable to provide evidence of comprehensive wound assessment or care during the resident's stay, resulting in a failure to provide necessary care and services to promote healing and prevent the development of new pressure injuries.