Failure to Timely Administer and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for pressure ulcer management for one resident. Upon admission, staff did not document a description of the resident's wounds, including location, stage, size, or other required characteristics, as outlined in the facility's wound management and skin integrity policies. The baseline care plan for the resident was left blank regarding skin issues, and progress notes lacked any wound description upon admission. The resident was admitted with significant medical conditions, including paraplegia, diabetes, heart failure, and multiple pressure ulcers: two suspected deep tissue injuries (DTIs) on the heels and a Stage IV pressure ulcer on the sacrum, all present on admission. Physician orders for wound care were not timely administered or documented. The Treatment Administration Record (TAR) showed multiple missed or undocumented treatments for the resident's wounds, including the sacral pressure ulcer and both heel DTIs. There were no entries for some ordered treatments on specific dates, and staff failed to document reasons for missed treatments. Interviews with nursing staff, the wound nurse, and the DON confirmed that a blank on the TAR indicated the treatment was not done, and there was no documentation that the physician was notified of delays or missed treatments. The wound doctor and corporate nurse both stated that staff were expected to follow physician orders and facility policies, but were unaware of the lapses in documentation and administration until after the fact. The facility's policies required comprehensive skin assessments and timely documentation of wound characteristics and treatments, as well as prompt notification of the physician and other relevant parties when wounds were identified or when treatment orders were absent. Despite these policies, the resident's wounds were not properly assessed or documented on admission, and there were significant gaps in the administration and documentation of prescribed wound care treatments. These failures were confirmed through record review, staff interviews, and review of the facility's own policies and procedures.