Failure to Timely Assess, Document, and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents. Several residents were admitted with existing pressure ulcers at various stages, but the facility did not consistently perform timely initial wound assessments, weekly reassessments, or implement treatment interventions as required. For example, one resident was admitted with multiple stage 3 and 4 pressure ulcers, but the first documented wound assessments were not completed until several weeks after admission. Nursing staff confirmed that initial wound assessments, including measurements and wound bed descriptions, should be completed on the day of admission, but this was not done. Additionally, weekly wound assessments and documentation were not consistently performed, and treatments were not always initiated promptly upon identification of new or worsening wounds. Another resident developed a pressure wound that was not treated for 26 days after it was identified, resulting in deterioration to a stage 4 ulcer. The care plan for this resident included daily skin inspections and nutritional support, but there was no evidence that the recommended protein supplement was provided. Wound assessments were missing for several weeks, and treatment orders were delayed. The wound care nurse and DON acknowledged that floor nurses are responsible for initial wound assessments and that treatments should be started as soon as possible, but this did not occur. The wound physician noted that wounds should be identified at earlier stages and emphasized the importance of high-protein supplements and offloading for prevention and healing. A third resident with severe cognitive deficits and total dependence on staff developed multiple pressure ulcers, including stage 3 and 4 wounds, which were not identified until they had progressed to advanced stages. The facility's policy required skin assessments on admission and weekly thereafter, but documentation showed gaps in assessments and delayed identification of wounds. Another resident with a history of noncompliance and high risk for skin breakdown had a stage 4 sacral wound that was not assessed for nearly three months, and new wounds were not promptly identified or treated. Staff interviews revealed that wounds were not always discovered during routine care, and appropriate offloading devices were not consistently used, despite the resident's high risk and previous wound history.