Delayed Pressure Ulcer Treatment Orders for High-Risk Resident
Penalty
Summary
A resident with Alzheimer's dementia, depression, and anxiety was admitted to the facility and identified as high risk for pressure injuries based on the Braden Scale. Upon admission, the resident had a pressure injury to the coccyx, which was documented as non-staged. The admission assessment indicated that the wound care company was notified and scheduled to see the resident on a future date. However, the resident was not seen by the wound care provider as planned, and no treatment orders were obtained at the time of admission. It was not until approximately 13 days after admission that a wound assessment was completed by the wound care physician, and specific treatment orders were initiated. During this period, the resident's wound care was delayed, as confirmed by interviews with the Director of Nursing and Assistant Director of Nursing, who acknowledged that wound treatment should be obtained as soon as a wound is discovered. Facility policy requires prompt identification and treatment of pressure ulcers, but this was not followed in the resident's case.