Failure to Timely Obtain Treatment Order for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to obtain a treatment order for a suspected deep tissue injury (DTI) on a resident's left heel at the time it was first observed, resulting in a delay in the initiation of treatment. The resident had multiple chronic health conditions, including diabetes, chronic kidney disease, obesity, and recent left total knee arthroplasty, and was identified as being at risk for pressure ulcers. The care plan included interventions such as regular skin assessments and preventative measures, but when the DTI was identified during a skin assessment, no immediate treatment order was obtained or implemented. The Wound Nurse observed the suspected DTI on the resident's left heel during a skin assessment and believed an order had been placed, but there was no evidence of a treatment order in the resident's Treatment Administration Record (TAR) for January. The Wound Nurse was unsure why the order was not present. The Wound Nurse Practitioner (NP) was only informed of the DTI several days later during wound rounds, at which point a treatment order was finally placed and initiated. Interviews with facility staff, including the NP, DON, and Administrator, confirmed that the expected protocol was to notify a provider and obtain a treatment order immediately upon identification of a pressure ulcer. Documentation review showed that the resident's care plan was not updated to reflect the DTI until several days after its initial observation, and treatment was not started until after the Wound NP was notified. The delay in obtaining a treatment order and initiating care for the pressure ulcer was confirmed through interviews and record review, constituting a failure to provide timely and appropriate pressure ulcer care as required.