Failure to Provide Pressure Ulcer Treatment Upon Admission
Penalty
Summary
Facility staff failed to obtain and provide pressure ulcer treatment for a resident who was admitted from the hospital with a stage II pressure ulcer to the sacral region. Upon admission, the resident's medical record and skin assessment documented the presence of a 3.5 cm by 2.8 cm pressure ulcer with a depth of 1.5 cm, and the hospital discharge summary indicated the need for dressing changes 1-2 times daily. Despite these findings, there was no evidence in the electronic medical record from admission through discharge that any treatment was ordered or completed for the pressure ulcer. The resident, who had diagnoses including chronic pain, adult failure to thrive, malnutrition, and alcohol use, reported to staff that the wound was not being treated or assessed. The resident subsequently decided to leave the facility, citing the lack of wound care as the reason. An interview with the DON confirmed that no admission orders for wound care were obtained, staff did not contact the resident's physician for a treatment order, and the facility did not have a current policy for pressure ulcer care and management.