Failure to Accurately Assess and Timely Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure accurate wound assessments and timely implementation of physician-ordered treatments for a resident with significant medical conditions, including osteomyelitis, peripheral vascular disease, and cellulitis. Upon admission, the resident had no documented pressure ulcers, only surgical incisions, as confirmed by both hospital discharge records and the facility's nursing admission evaluation. However, subsequent documentation, including the Minimum Data Set (MDS) and care plan, indicated the presence of a Stage III pressure ulcer on the right buttock as present upon admission, despite no prior skin assessment or documentation supporting this finding. The first wound assessment and treatment order for the pressure ulcer were not completed until several days after admission. Further review revealed that the nurse practitioner assessed the resident and provided a treatment order for the Stage III pressure ulcer, but failed to enter the order into the computer system until nine days later. As a result, the prescribed wound care was not initiated until this delay was rectified. Interviews with facility staff confirmed the lack of timely documentation and implementation of wound care orders, as well as the absence of an initial skin assessment identifying the pressure ulcer. The facility's policy required prompt review, selection, and documentation of appropriate wound treatments, which was not followed in this case.