Failure to Obtain Timely Wound Treatment Orders and Provide Pressure Ulcer Care
Penalty
Summary
The facility failed to obtain wound treatment orders and provide appropriate wound care upon admission for a resident who was admitted with a stage 2 pressure ulcer on the sacrum. Upon admission, the wound was documented and a new dressing was applied, but no treatment orders were obtained, and there was no alert charting or documentation of wound care in the medical record. The resident's weekly skin checks continued to note the presence of the sacral wound, but it was not until several days later that a treatment order was finally obtained. During this period, nursing staff reported providing wound care without an order, but did not document these interventions or notify the provider as required. Interviews with facility staff revealed that the wound nurse who initially assessed the resident resigned without obtaining a treatment order, and subsequent staff were unaware of the wound due to lack of communication in nursing reports and absence of alert charting. The wound physician was not made aware of the lack of treatment until after the delay, and the wound was later found to be unstageable and required debridement. The facility's policy required prompt identification and individualized care planning for pressure ulcers, but this was not followed in the resident's case, resulting in a delay in appropriate wound management.