Delayed Pressure Ulcer Treatment and Incomplete Skin Assessments
Penalty
Summary
The facility failed to obtain timely treatment orders for pressure ulcers identified on a newly admitted resident, resulting in a seven-day delay before wound care was initiated. Upon admission, the resident was noted to have pressure ulcers on the right and left buttock and sacrum, with documentation indicating the skin was not intact and at moderate risk for further breakdown. However, the admission assessment and baseline care plan lacked complete information regarding the size, depth, and stage of the wounds, and no treatment orders were obtained or administered for the pressure ulcers during the first week of admission. Additionally, the facility did not perform accurate or consistent head-to-toe skin checks to identify new or existing pressure ulcers. Several skin assessments and daily skilled charting entries incorrectly documented the resident's skin as intact, despite the presence of pressure ulcers. The nurse responsible for the admission assessment did not measure the wounds or check for blanching, and later admitted to not being trained on the full process for new admissions or daily skilled charting. The Wound Care MD was not notified of the resident's wounds and did not evaluate the resident due to a rescheduled visit and lack of communication from the facility. Further observations revealed that wound care orders were not consistently followed, as the prescribed dressing was not always in place, and some wound care treatments were missed or not documented. A new deep tissue injury was later identified on the resident's left heel, which had not been previously documented. Interviews with staff indicated gaps in communication, training, and adherence to protocols for skin assessments and wound care, contributing to the delay in treatment and failure to prevent the development of new pressure ulcers.