Failure to Timely Identify and Treat Pressure Ulcers on Admission
Penalty
Summary
The facility failed to ensure timely identification and treatment of pressure ulcers for a resident who was readmitted following a hospital stay. Upon readmission, the resident's hospital discharge summary documented deep tissue pressure injuries (DTPI) on both ankles. However, the nursing admission assessment and total body skin assessment completed by two LPNs did not identify or document any ankle or foot wounds, and both assessments indicated no new wounds or skin conditions. Interviews with the LPNs revealed they could not recall specifically inspecting the resident's feet or ankles during the assessments, though it was acknowledged that a full body inspection was expected. The pressure ulcers were not identified by facility staff until 15 days after the resident's readmission, when a change in condition note prompted a wound care physician consult. The subsequent wound care assessment confirmed the presence of deep tissue injuries on both feet, which were present on admission. Facility policy required a baseline total body skin evaluation upon admission and prompt documentation and intervention for any skin impairments, but these steps were not followed, resulting in a delay in the identification and treatment of the resident's pressure ulcers.