Failure to Provide Timely Pressure Ulcer Care and Assessment
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for two residents. One resident, admitted with a history of cerebral infarction, was documented by the Wound Nurse Practitioner (WNP) to have an unstageable sacral pressure ulcer. The prescribed treatment regimen included cleansing with dakins and applying santyl with dakins wet to dry dressing daily. However, medical record review showed that staff did not administer the ordered treatment on three consecutive days, as confirmed by the Director of Nursing. Another resident, who was readmitted from the hospital, was assessed by the WNP to have a Stage 3 sacral pressure ulcer. Facility staff failed to complete weekly wound assessments, including measurements, on three separate occasions. Additionally, although a left heel wound was identified, treatment for a deep tissue injury (DTI) was not initiated until nearly two weeks after the wound was first documented. The Assistant Director of Nursing confirmed these lapses in wound assessment and delayed initiation of treatment.