Failure to Timely Identify and Document New Pressure Ulcer
Penalty
Summary
The facility failed to identify a stage 2 pressure ulcer in a timely manner for a resident with multiple risk factors, including polyneuropathy, diabetes, end stage renal disease, and impaired mobility. During a skin check, a new pressure wound was discovered in the upper intergluteal cleft by two LPNs and the surveyor, with both nurses acknowledging they were previously unaware of the wound. The resident's care plan indicated a high risk for pressure ulcers and included interventions such as regular skin inspections during showers, use of pressure-reducing devices, and prompt reporting of skin breakdown. However, documentation on shower sheets and treatment administration records did not reflect the presence of the new wound prior to its discovery. The resident required supervision and assistance with activities of daily living and was known to have other unstageable pressure ulcers. Despite these risk factors and the facility's policy for routine skin assessments and immediate reporting of developing pressure injuries, the new stage 2 pressure ulcer was not identified or documented until the surveyor's observation. The lack of timely identification and documentation represents a failure to follow established protocols for pressure ulcer prevention and monitoring.