Delay in Treatment of Newly Identified Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely treatment of a newly identified pressure ulcer for a resident with significant medical conditions, including quadriplegia, malnutrition, muscle wasting, and multiple contractures. Upon review, the resident was admitted with multiple pressure ulcers and later developed a new stage III pressure ulcer on the right inferior hip. Documentation showed that the wound was identified during a wound care physician visit, but there were no specific treatment orders for the new wound upon the resident's return to the facility. The resident's care plan and wound observation tool noted the presence of the new wound, but the treatment being provided was for a different, pre-existing wound. Staff interviews and record reviews revealed that the lack of clear treatment orders for the new wound led to a delay in implementing appropriate care. The resident care manager was unable to clarify the necessary orders with the wound care physician for several days, resulting in no documented wound treatment for the new pressure ulcer between its identification and the eventual receipt of orders. The facility's policy required prompt attention and potential changes to the care plan when skin breakdown occurs, but this was not followed in this instance.