Delay in Pressure Ulcer Treatment Leads to Stage 3 Wound
Penalty
Summary
A resident with diagnoses including dementia, heart disease, and kidney disease, and with severely impaired cognition, was admitted to the facility and later developed a facility-acquired Stage 3 pressure ulcer. On initial assessment, a wound was identified on the resident's sacrum by an LPN, who reported the finding to the wound care nurse and applied a dressing. However, the LPN did not document a progress note or notify the physician for wound treatment orders at that time. There was a delay in obtaining treatment orders and implementing interventions, as the wound care nurse was not present on weekends and only initiated appropriate care two days after the wound was first identified. The contracted wound provider subsequently assessed the wound and documented it as a Stage 3 pressure injury. The facility's acting Director of Nursing acknowledged that the delay in treatment orders and interventions contributed to the development of the Stage 3 pressure ulcer.