Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate wound care and prevent the development and worsening of pressure ulcers for two residents. For one resident with a history of traumatic brain injury and severe cognitive impairment, weekly skin assessments were inconsistently performed, with a significant gap of nearly a month between assessments. The resident developed a facility-acquired, unstageable pressure ulcer on the left ankle, which progressively worsened over several weeks. Documentation showed multiple missed dressing changes in both June and July, and the physician's progress notes did not reference the pressure ulcer, its avoidability, or a treatment plan. Additionally, the care plan for the wound was not implemented until over seven weeks after the wound was first identified. For another resident with dysphagia and a gastrostomy, a skin tear was identified on the right gluteus area upon admission, but no physician orders for treatment were found in the record, and no treatments were documented as administered during the resident's stay. The DON confirmed that a physician's order and care plan should have been implemented for the wound upon admission, but this did not occur. These failures demonstrate lapses in wound identification, timely assessment, documentation, and implementation of appropriate treatment protocols.