Failure to Identify Pressure Ulcer on Admission
Penalty
Summary
The facility failed to conduct a thorough skin assessment upon admission for a resident who was admitted with a history of stroke, resulting in full body hemiparesis/hemiplegia and total dependence for all activities of daily living. Initial admission assessments documented that the resident did not have any pressure ulcers, but did note excoriation, bruises, and a laceration. The resident was bedbound and required tube feeding. Several days after admission, staff discovered a large, necrotic wound on the back of the resident's head while attempting to wash her hair, which had been matted. The wound was subsequently identified as an unstageable pressure ulcer and later reclassified as a stage IV pressure ulcer after debridement. The wound was not documented or identified during the initial admission assessments, despite the resident's immobility and high risk for pressure injuries. The wound was only discovered after a delayed inspection, and there was no evidence in the hospital records that the wound was present prior to admission. The facility's policy required a comprehensive head-to-toe skin assessment within 24 hours of admission, but the wound was missed during this process, resulting in a delay in implementing appropriate pressure ulcer treatment.