Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice, resulting in deficiencies for two residents. One resident with a history of pressure injuries and multiple comorbidities, including diabetes, morbid obesity, and vascular disease, was readmitted to the facility without a comprehensive skin assessment by an RN. Upon readmission, redness was noted by an LPN on the coccyx and buttocks, but no measurements or detailed characteristics were documented, and no RN assessment was completed. It was not until a scheduled wound physician visit several days later that three Stage 3 pressure injuries were identified and treatment was initiated. Prior to this, there was no documentation of preventive treatments or interventions, such as barrier cream, and no evidence that staff were consistently implementing care plan interventions like repositioning with a draw sheet or using positioning devices. Interviews revealed that staff were unclear about the resident's repositioning needs, and the resident reported never being offered pillows or assistance for offloading pressure. Another resident was readmitted with a known Stage 3 pressure injury to the right fifth toe. Although the wound was documented upon readmission, there were no treatment orders for five days, and no wound care was completed until a week later. The treatment administration record (TAR) did not reflect a scheduled daily treatment order, and the first documented treatment occurred only after the wound physician assessed and debrided the wound. The care plan included pressure-relieving devices and protocols for injury treatment, but these were not implemented in a timely manner. Interviews with the wound nurse confirmed that the treatment order should have been placed and initiated upon readmission, but this did not occur. Observations and interviews throughout the survey period highlighted lapses in communication, documentation, and adherence to facility policy regarding skin assessments and pressure injury prevention. Staff were not consistently aware of or implementing individualized care plan interventions, and there was a lack of timely and comprehensive assessment and treatment for residents at risk for or with existing pressure injuries. These failures resulted in delayed identification and management of pressure injuries, contrary to professional standards and facility policy.