Failure to Assess and Treat Pressure Ulcers as Ordered
Penalty
Summary
The facility failed to assess wounds and complete wound treatments as required for two residents with pressure sores. For one resident, there was no admission skin or wound assessment performed by facility staff, nor were there any weekly skin or wound assessments documented after admission. The resident was admitted with only a surgical wound, but later developed a large, unstageable deep tissue injury on the posterior right upper buttock. The treatment administration record showed that wound care treatments were missed on multiple days, and the resident's family observed that dressings were often not changed as scheduled, with old dressings remaining in place. The Director of Nursing confirmed the lack of required assessments and missed treatments, acknowledging that treatments were not completed as ordered by the physician. Another resident, admitted with multiple diagnoses including Parkinson's disease, dementia, and a history of malignancy, also did not receive required weekly skin or wound assessments. The treatment administration record indicated that wound care for a sacral pressure ulcer was not completed as ordered on several occasions. The last documented skin or wound assessment for this resident was several weeks prior to the survey, despite ongoing physician orders for wound care. During wound care observations, the wound was found to have full-thickness tissue loss with muscle exposed, and the resident experienced pain during the procedure. Facility policy required comprehensive skin assessments upon admission, weekly risk assessments, and completion of wound care according to physician orders. Interviews with the Director of Nursing and review of records confirmed that these policies were not followed for the two residents. The failure to perform timely assessments and complete wound treatments as ordered led to the deficiencies cited in the report.