Failure to Assess and Treat Pressure Ulcer as Ordered
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer was properly assessed and provided with necessary treatment and services consistent with professional standards of practice. The resident, who had diagnoses including hypotension, protein-calorie malnutrition, and diabetes, was identified as being at moderate risk for developing pressure ulcers according to the Braden Scale. Upon admission, a new open area on the coccyx was noted, and a physician order was in place for weekly skin assessments. However, documentation showed that these weekly skin assessments were not completed on several occasions as ordered. Additionally, there was a lack of comprehensive wound assessment and wound treatment orders for the resident from the time the skin issue was first identified until over two weeks later. Progress notes indicated that the skin issue had not been evaluated during this period, and wound care orders were not initiated until much later. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the failure to assess and provide necessary treatment and services for the resident's pressure ulcer.