Failure to Provide Timely Pressure Ulcer Care and Obtain Physician Orders
Penalty
Summary
Facility staff failed to provide care in accordance with professional standards for pressure ulcers for one resident. Upon admission, the resident had multiple stage 2 pressure ulcers on the buttocks and coccyx, as well as a surgical incision with a wound vac. The facility's own policies required prompt risk assessment, documentation, physician notification, and establishment of wound care interventions. However, staff did not obtain physician orders for wound treatments or the wound vac, nor did they document or initiate any wound care for the identified pressure ulcers. The baseline care plan did not address care or treatment for the wounds, and there were no specific wound care instructions from the discharging hospital. Review of the resident's records showed that the wounds were present on admission, but staff failed to document wound treatments or obtain orders for several days. Progress notes and treatment administration records lacked any documentation of wound care or interventions for the pressure ulcers or the wound vac. Multiple staff interviews confirmed that while some were aware of the wounds, no treatments had been initiated, and there was confusion regarding documentation and responsibility for obtaining orders. The DON and Administrator both stated that they expected staff to assess, document, and initiate treatment for wounds upon admission, but this did not occur. The resident reported ongoing pain from the wounds and stated that staff had been informed of the wounds since admission, but no action was taken. Observations confirmed the presence of untreated wounds with partial thickness skin loss and slough tissue. It was only after several days that a physician order for topical zinc oxide was obtained. The facility failed to follow its own policies for wound assessment, documentation, and timely intervention, resulting in a lack of appropriate care for the resident's pressure ulcers.