Failure to Provide Timely Pressure Ulcer Assessment and Nutritional Support
Penalty
Summary
A resident with a history of dementia, left femur fracture, and severe cognitive impairment was admitted and later readmitted to the facility. Upon readmission, the resident was identified as being at risk for pressure ulcers but had intact skin except for facial bruising. The care plan included interventions for skin integrity, such as barrier cream application and weekly skin checks. However, a new blister with slough was first documented on the resident's left heel during a weekly skin check, but it was not recognized as a new pressure ulcer by the nursing staff at that time. Both the RN and LPN who identified the left heel blister assumed it was an old injury and did not notify the RN supervisor or initiate a change of condition assessment as required by facility policy. As a result, no wound assessment or treatment was initiated for nine days after the initial identification of the pressure area. The first complete RN wound assessment and physician notification occurred only after the wound had deteriorated and was identified as an unstageable deep tissue injury (DTI). During this period, the resident did not receive appropriate wound care or interventions to address the new pressure ulcer. Additionally, the facility failed to notify the dietitian of the new pressure ulcer in a timely manner. The dietitian did not receive wound reports for the relevant period and was not made aware of the resident's new pressure ulcer until 49 days after its initial identification. Consequently, the resident did not receive a nutritional assessment or recommended protein supplementation to support wound healing until this late notification. These failures were contrary to the facility's policies on pressure injury prevention, management, and nutritional support.