Failure to Provide Timely and Accurate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for three residents, resulting in actual harm to one resident and placing two others at risk for more than minimal harm. For one resident with a history of acute embolism, muscle weakness, and diabetes, the facility did not initiate treatment or complete an accurate assessment for a suspected deep tissue injury (SDTI) to the bilateral buttocks upon admission, despite clear hospital discharge instructions and recommendations from a Wound Certified Nurse Practitioner (CNP). The SDTI was not measured or documented by facility staff, and the prescribed triad cream treatment was not ordered or administered. The resident, who was cognitively intact, reported that no cream had been applied since admission and only refused care due to pain, which could have been managed with pre-medication. The lack of assessment and treatment led to the SDTI worsening into four stage III pressure ulcers. Another resident with dementia, cerebral infarction, and chronic kidney disease was admitted with an unstageable pressure ulcer on the left elbow, but no treatment order was in place until the day after admission. Additionally, a stage II pressure ulcer to the scrotum was identified, but treatment was delayed for two days after documentation. The care plan for this resident did not include interventions for wound treatments as ordered, contrary to facility policy requiring timely and evidence-based treatment for pressure injuries. A third resident with pressure ulcers on both heels had an order for pressure relief boots that was discontinued by staff without a physician's order. Furthermore, there was no documentation that prescribed wound treatments for both heels were completed on several dates. The DON confirmed that treatments were not completed as ordered. Facility policies required full body skin assessments upon admission, weekly assessments, and adherence to physician orders for wound care, but these were not followed for the residents involved.