Failure to Initiate Timely Pressure Ulcer Treatment on Admission
Penalty
Summary
A resident was admitted to the facility with a history of femur fracture, anemia, multiple myeloma, and prior stroke. Upon admission, the resident was found to have Stage 2 pressure ulcers on both buttocks, as documented by the admitting nurse. However, there was no evidence that the physician was notified of these wounds or that wound care treatment orders were obtained at the time of admission. The only order present was for the application of barrier cream after incontinence episodes, which was not documented as being administered in the treatment records. Despite facility standing orders requiring cleansing and dressing of Stage 2 wounds and physician notification, these protocols were not initiated until several days after admission. The wounds were not properly assessed or treated according to the facility's own guidelines, and the resident was not referred to the Wound Care Physician until six days after admission. During this period, there was no documentation of wound progression or further assessment, and the right buttock wound deteriorated to an unstageable deep tissue injury requiring debridement. Interviews with nursing staff and the Wound Care Physician confirmed that the initial wounds were not managed appropriately, and the necessary wound care interventions were delayed. The Wound Care Physician and Nurse Practitioner both indicated that the use of barrier cream alone was insufficient for Stage 2 wounds and that a more comprehensive wound care regimen should have been implemented immediately. The lack of timely notification, assessment, and treatment contributed to the progression of the resident's pressure ulcer.