Failure to Provide Timely Wound Care for Pressure Ulcer on Admission
Penalty
Summary
A deficiency occurred when staff failed to provide timely and appropriate wound care for a resident admitted with a stage 2 pressure ulcer. Upon admission, the resident had an existing wound, but staff did not obtain wound care orders until three days later. Documentation shows that wound care was not performed or recorded on the day of admission and for several subsequent days. The Treatment Administration Record for the relevant period lacked entries indicating that wound care was provided, and there were no progress notes explaining the omission. Interviews with facility staff revealed that the Wound Care Nurse was not present at the time of admission and only assessed the resident's wound several days later. The Director of Nursing confirmed that the expectation is for nurses to obtain care orders and provide wound care within the first 48 hours of admission. However, this protocol was not followed, resulting in a lack of consistent wound management for the resident during the initial days of their stay.