Failure to Initiate Timely Wound Care for Pressure Ulcers Upon Admission
Penalty
Summary
The facility failed to initiate wound care upon admission for a resident with multiple pressure ulcers. Upon admission, the resident had a documented history of a right thigh decubitus ulcer, with hospital discharge instructions to continue wound care. Initial assessments by nursing staff noted bruises and dry skin, but did not identify or document any open wounds or pressure ulcers. No wound care orders or treatments were initiated at this time, and there was no documentation of wound care being provided prior to new physician orders being placed several days after admission. Subsequent assessments revealed multiple pressure ulcers and deep tissue injuries (DTIs) on the resident, including wounds on the right and left feet, right upper thigh, sacrum, and ischium. Wound care orders were eventually obtained and documented, but not until several days after admission, resulting in a delay in treatment. Interviews with facility leadership confirmed that wound care should have been started earlier and that any wounds identified upon admission should have been documented, assessed, and treated promptly.