Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to obtain timely treatment orders and complete physician-ordered treatments for a resident with pressure ulcers. The resident, who had diagnoses including congestive heart failure, pneumonia, urinary tract infection, and type 2 diabetes, was identified as high risk for pressure ulcer development and had a care plan in place for skin breakdown prevention. Despite documentation of abnormal findings on the left heel on multiple shower sheets, there were no corresponding progress notes, treatments, or orders on those dates. The weekly wound evaluation did not document the left heel until it was identified as a stage 3 ulcer, and the treatment order for the left heel was not obtained until several days after abnormalities were first noted. Additionally, the treatment administration records showed that the ordered treatments for the left heel were not completed on the first two days after the order was written. Interviews with facility staff confirmed that documentation and treatment for the left heel were lacking, and that the wound was not addressed in a timely manner. The wound nurse stated that the left heel was not open prior to the treatment order, but there was no documentation of assessment or intervention when the area was first identified as abnormal. The facility's policy requires assessment and documentation of risk factors and skin breakdown, but this was not followed for the resident's left heel, resulting in a delay in treatment and incomplete documentation.