Failure to Provide Timely Pressure Ulcer Treatment and Prevention
Penalty
Summary
A deficiency occurred when the facility failed to provide timely and adequate treatment and interventions to prevent the worsening of a pressure ulcer for one resident. The resident, who required significant assistance with mobility and transfers, developed an open area on the right heel that was initially identified as a bruise. Over time, the area progressed to a stage 2 pressure ulcer, and later to a stage 3 ulcer with necrotic tissue and slough. Despite the change in the wound's condition, no treatment or dressing was applied to the right heel for eight days, from the time the area became open until the visiting wound care nurse assessed the wound and initiated treatment orders. Documentation and interviews revealed that the facility staff recognized the change in the wound on the right heel, including the presence of a blister, crack, and drainage. The Director of Nursing (DON) and other staff acknowledged that the area was not just a bruise but had become an open wound. However, there was no evidence that the primary physician was notified or that a request for wound treatment was made during this period. The wound care nurse, upon arrival, noted that the wound was unstageable due to eschar and slough, and expressed concern that no dressing or treatment had been started prior to her visit. The resident was observed resting the affected heel on the bed frame without protective boots, further contributing to the pressure and injury. The facility's own policies required physician notification and wound care orders for abnormalities such as wounds, but these steps were not followed. Communication lapses between facility staff and providers contributed to the delay in care, as the resident's primary provider was not informed of the wound's progression. Staff interviews confirmed that no dressing or treatment was applied to the open area until the wound care nurse's assessment, despite the wound being at least a stage 2 ulcer at the time it became open.