Failure to Assess and Monitor Pressure Ulcer Progression
Penalty
Summary
The facility failed to assess and implement appropriate treatment and services to promote the healing of a pressure ulcer for one resident. According to the facility's Pressure Injury Treatment Protocol, all pressure injuries are to be assessed weekly and as needed, with specific actions required if the wound does not improve within 14 days. Clinical records show that a resident was admitted with a Stage 2 sacral pressure ulcer, which was initially measured and assessed by a wound care specialist on two occasions within the first nine days of admission. However, after April 24, there was a gap of three weeks without any documented assessment of the wound. During this period without assessment, the resident's pressure ulcer progressed from Stage 2 to Stage 3, indicating a deterioration in the wound. The Director of Nursing confirmed that the pressure ulcer was not assessed at least weekly as required, and that documentation of the wound's date observed, location, staging, and size was missing for the three-week period. This failure to follow the facility's protocol resulted in a lack of timely evaluation and intervention for the resident's pressure ulcer.