Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for pressure ulcer prevention and treatment for one resident. Upon admission, the resident had no pressure ulcers, but subsequently developed open areas on the right and left buttocks. The right buttock wound was first noted as a small open area, but there was no documentation that the provider was notified or that a physician's order was obtained for treatment for six days. During this period, the wound worsened and was later assessed as an unstageable pressure ulcer. Treatment orders were not obtained until several days after the wound was identified, and the treatment was not documented as completed until two days after the order was written. For the left buttock, a stage 2 pressure ulcer was identified, but there was no treatment ordered or documented for a period of three weeks. Additionally, there was a lack of weekly documentation of the size and measurements of both the right and left buttock pressure ulcers for extended periods after their identification. Interviews with nursing staff confirmed that wounds were not measured or documented as required, and that treatment orders were delayed or not followed according to physician instructions. During wound care observations, staff did not follow physician's orders for wound treatments and failed to take measurements of wounds at the time of dressing changes. Facility policies required wound treatment to be provided in accordance with physician orders, prompt notification of providers for new wounds, and regular documentation of wound characteristics and measurements. These policies were not followed, resulting in incomplete and delayed care for the resident's pressure ulcers.