Failure to Consistently Complete Wound Treatments and Timely Identify Pressure Ulcers
Penalty
Summary
The facility failed to consistently complete wound treatments and timely identify and treat pressure ulcers for two residents reviewed for wounds. For one resident, the medical record showed that wound care orders for the sacrum, right buttock, and left heel were not followed as prescribed, with treatments omitted on specific dates. Additionally, staff applied a prescribed ointment more frequently than ordered. The resident required assistance with all activities of daily living and had multiple wounds documented upon admission. For another resident, there was a delay in the identification and treatment of a left heel wound. Although a clinician noted a possible pressure ulcer and recommended close monitoring and a wound care consult, nursing staff did not acknowledge the wound until two days later, and treatment orders were not implemented until six days after the initial identification. The resident also required staff assistance for most activities of daily living and had no pressure wounds documented at admission. The facility also failed to consistently complete and document weekly skin assessments as required by policy. In one instance, a weekly skin assessment was marked as completed in the medical record, but no supporting documentation was found. Interviews with facility staff confirmed that wound treatments were sometimes missed when the wound nurse was off duty and that communication lapses contributed to delays in wound identification and treatment.