Failure to Timely Assess and Intervene for Facility-Acquired Pressure Ulcer
Penalty
Summary
A deficiency was identified when a resident, assessed as low risk for pressure ulcers, developed a facility-acquired pressure ulcer. Initial nursing documentation noted blanchable, thick, hard, indurated skin on the left buttock, but no wound assessment was completed at the time of identification. The physician and family were notified, but subsequent progress notes and monthly summaries failed to address or document the new wound. There was a lack of timely and thorough wound assessment, as the wound was not measured or staged until ten days after initial identification, at which point it was found to be an unstageable pressure injury by the wound specialist. The care plan for the resident included general interventions for skin integrity, such as barrier cream and preventative skincare, but no new interventions were added when the wound was first identified. Documentation conflicted regarding when specialty support surfaces were provided, and there were no corresponding physician orders or care plan entries for these interventions at the time of wound identification. Treatment orders for the wound were not initiated until several days after the wound was first noted, and the first administration of the treatment occurred a week later. Interviews with the DON confirmed that the wound was facility-acquired and that an initial assessment and documentation were not completed as required. The DON acknowledged that a documented assessment and measurement should have occurred when the wound was first identified. Facility policy required evaluation, reporting, and documentation of skin changes, as well as ongoing review of interventions, but these steps were not followed in this case.