Failure to Obtain Timely Wound Treatment Orders for Pressure Injuries
Penalty
Summary
The facility failed to obtain timely wound treatment orders when pressure injuries were identified for two residents. For one resident admitted with surgical aftercare and muscle weakness, a new mixed stage 1-2 pressure injury was identified during care, and although the medical doctor was notified and orders were reportedly received, no treatment orders were entered into the electronic medical record (EMR) during the resident's stay. The care plan did not address the pressure injury until several days later, and the wound was not entered into the facility's risk management system. Interviews with nursing staff and administration confirmed that the expected process of documenting the wound, obtaining and entering orders, and updating the care plan was not followed. Another resident, admitted with diabetes and vascular dementia, had a stage three pressure injury to the coccyx upon admission. Documentation showed that no treatment order for this wound was entered until two weeks after admission, despite the presence of the wound being noted in nursing assessments. The only order present on admission was for a moisture barrier cream, which was not signed off as administered. The facility's wound nurse confirmed that there was no wound nurse or system in place prior to her tenure, and that treatment orders were not obtained in a timely manner for this resident's pressure injury. Facility policy required collaboration with the interdisciplinary team, prompt skin assessments, provider notification, and timely updates to care plans and treatment orders for any abnormal skin findings. However, in both cases, the process for obtaining and documenting wound care orders was not followed, resulting in a lack of timely treatment for identified pressure injuries.