Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to provide care and services for pressure ulcers in accordance with professional standards of practice, as evidenced by the lack of weekly assessments and failure to administer wound treatments as ordered for three residents. Facility policy required weekly wound evaluations, but documentation showed that pressure ulcers for the affected residents were not assessed at the required intervals. For one resident, pressure ulcer assessments were not documented between two specific dates, and for another, prior assessments could not be located in the electronic health record for a recurring pressure ulcer. One resident returned from the hospital with pressure ulcers to the sacrum and left lateral foot. Nursing notes indicated issues with the facility's wound photo application, resulting in incomplete documentation of wound measurements and assessments. The Treatment Administration Record (TAR) showed that prescribed wound care treatments were not signed off as performed for multiple days, and there was no documentation of resident refusal for these treatments, despite the care plan noting a history of resistive behavior. The Center Nurse Executive confirmed that there was no evidence the required dressing changes or assessments were completed or documented. Another resident had a pressure ulcer to the left elbow that had healed and reoccurred, but no prior assessments were found in the medical record for the most recent occurrence. A third resident developed a sacral pressure ulcer, which was not assessed for a period of nearly two weeks. The lack of timely and complete assessments and failure to document or perform ordered treatments resulted in actual harm to one resident, who was hospitalized with a pressure ulcer infection and diagnosed with septic shock believed to be related to the infected wound.