Failure to Timely Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to timely and comprehensively assess and document pressure ulcers, as well as to follow physician wound treatment orders for multiple residents. For one resident with quadriplegia, epilepsy, protein-calorie malnutrition, and psychiatric disorders, the care plan required frequent repositioning and skin monitoring due to high risk for skin breakdown. Despite weekly skin checks indicating no new issues, a nurse later discovered a significant sacral wound, which was ultimately identified as a Stage 3 pressure ulcer. There was no clinical documentation of a preceding blister or prior sacral wound, and treatment by the wound consultant was delayed due to the resident's unavailability. The pressure ulcer was not identified until it had progressed to Stage 3, and no treatments were in place for a blister prior to this discovery. Another resident was admitted with a history of acute respiratory failure and was found to have a Stage 3 pressure ulcer on the left buttock. Although the wound was identified upon admission, a comprehensive assessment of the wound's size and condition was not completed until six days later. The Director of Nursing confirmed this delay in assessment, indicating a lapse in timely wound evaluation and documentation as required by facility policy. A third resident was admitted with a Stage 4 sacral pressure ulcer, and a wound care order was issued by the wound physician. However, the order was not implemented until four days after it was written, due to a delay in entering the order into the electronic medical record. The responsible nurse acknowledged the delay was due to not entering the order promptly. These failures resulted in noncompliance with facility policies and state regulations regarding timely assessment, documentation, and implementation of wound care for residents at risk for or experiencing pressure ulcers.