Failure to Timely Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly assess, document, and initiate timely treatment for pressure ulcers in a resident with multiple medical conditions, including failure to thrive, dementia, right hemiplegia, and paranoid schizophrenia. Upon readmission from the hospital, the resident was documented to have a pressure ulcer on the right buttock and a deep tissue injury (DTI) to the coccyx, as well as a surgical incision on the right knee. Initial assessments by facility staff noted these wounds, but there was no evidence that appropriate treatments were ordered or initiated for the DTI to the coccyx or the open area to the right gluteal fold at that time. Further review of the medical record revealed a lack of weekly wound evaluations for the DTI to the coccyx and the right gluteal fold area between the initial assessment and a later evaluation, which did not occur until several weeks after the wounds were first identified. Physician orders for wound care to the sacrum were not placed until weeks after the wounds were observed, and there was no documentation of Enhanced Barrier Precautions or other interventions for the pressure ulcers during this period. Treatment records confirmed that only the surgical site on the right knee received timely care as ordered, while the pressure ulcers did not receive documented treatment until much later. Interviews with the DON confirmed that the facility did not have documentation to support timely initiation of treatments or completion of weekly wound measurements for the pressure ulcers. Observations of wound care performed by an LPN showed that wound care was eventually provided as ordered, but this occurred after a significant delay. Review of facility policy indicated that prompt assessment and treatment of pressure ulcers was required, but this was not followed in the case of this resident.