Failure to Accurately Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to accurately assess and document a resident's pressure wound and did not complete wound treatments as ordered. The resident, who had multiple diagnoses including diabetes mellitus, chronic ulcer, and osteomyelitis, required extensive assistance with mobility and had a history of a wound on the right heel. Despite ongoing wound care needs, the care plan did not include a current plan for pressure wound management. Facility wound assessments repeatedly described the wound as 'other' rather than identifying it as a pressure ulcer, and lacked detailed descriptions. The wound care center later identified the wound as a stage three pressure ulcer, but this information was not initially obtained or incorporated by the facility. Additionally, wound treatments were not performed according to physician orders. During an observation, a dressing on the resident's right heel was found to be several days old, despite orders for dressing changes three times weekly. The dressing showed yellow/green drainage, and staff confirmed the treatment had not been completed as scheduled. Facility policy required wound treatments to be completed per physician orders and for pressure ulcers to be differentiated from non-pressure ulcers, but these protocols were not followed.