Failure to Provide Consistent Pressure Ulcer Care and Assessments
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident with a history of a Stage III pressure ulcer on the right ankle. The resident was admitted in October 2022 with this diagnosis, and a Wound Nurse Practitioner assessed the wound as a Stage III pressure ulcer on 12/31/24. Medical record review revealed that staff did not complete required weekly skin assessments, including measurements and treatment recommendations, on 2/11, 2/18, 3/20, and 3/27/25. Additionally, after the resident returned from the hospital on 2/27/25, facility staff failed to provide any wound treatment for the right ankle pressure ulcer until 3/4/25, resulting in a five-day gap in care. The Director of Nursing confirmed that weekly skin assessments and wound treatments were not performed on the specified dates, indicating a lapse in the facility's pressure ulcer care and prevention protocols.