Failure to Provide Timely Wound Treatment Upon Admission
Penalty
Summary
The facility failed to provide wound treatment for a resident's left lower extremity open wound for three days following admission. Upon review, the resident was re-admitted with diagnoses including a non-pressure ulcer of the left foot and ankle and peripheral vascular disease. Hospital discharge documents and progress notes indicated the presence of open wounds on the resident's left lower and posterior leg and left foot. The skilled nursing facility's admission assessment also documented a skin breakdown on the left lower leg, and a Braden Skin Risk Assessment classified the resident as mild risk for pressure ulcers. However, there was no physician's order for wound treatment from the date of admission through the following three days, and the Treatment Administration Record showed no documentation of wound care being provided during this period. Interviews with facility staff revealed that the admitting RN did not obtain or clarify treatment orders for the resident's wounds, nor was the wound described in the medical records. The Quality Assurance Nurse and Assistant Director of Nursing confirmed that the expected process was for the admitting nurse to conduct a full body assessment, notify the physician, and secure treatment orders, with follow-up and shift endorsement if clarification was needed. The facility's policy required licensed nurses to notify the practitioner for any skin breakdown requiring treatment upon admission, but this was not followed, resulting in a lack of timely wound care for the resident.