Failure to Provide Timely Pressure Ulcer Assessment and Notification
Penalty
Summary
A deficiency was identified when a resident, admitted without pressure ulcers and assessed as having a mild risk for pressure sore development using the Braden Scale, developed an unstageable pressure ulcer to the sacral area while residing in the facility. The medical record review showed that the resident was admitted with diagnoses of morbid obesity and type 2 diabetes mellitus, and had no pressure ulcers at admission. Despite the resident's risk factors and the development of a new pressure ulcer, there was no documentation of a change in condition assessment being completed at the time the ulcer was identified. Further review revealed that the family representative was not notified of the change in the resident's condition, as confirmed by the DON. The wound continued to progress in size over time, as documented in subsequent wound assessments. The DON acknowledged that the facility's expectation is for nurses to complete a change in condition assessment and notify residents or their representatives of any change, but this was not done in this case.