Failure to Complete Timely Wound Assessments and Initiate Wound Care on Admission
Penalty
Summary
A resident was admitted with multiple advanced pressure ulcers, including stage IV ulcers on the left ischium, sacrum, and right hip, a stage II ulcer on the right buttock, a deep tissue injury on the left heel, and osteomyelitis requiring intravenous and oral antibiotics. Upon admission, the facility failed to complete initial wound assessments within the first 24 hours, as required. There was no documentation of wound descriptions with measurements or physician orders for wound care until two days after admission. The initial wound care orders and assessments were not entered until the Unit Manager returned to work, and the responsible nurses on the weekend of admission were agency staff who did not complete the necessary documentation or obtain wound care orders. The resident's hospital discharge instructions included follow-up with a wound center and specific antibiotic regimens but did not provide detailed wound care orders. The facility did not initiate wound care treatments or document wound assessments until several days after admission. Orders for wound vac therapy and alternative wound dressings were delayed, and some were not administered or documented as completed on the days they were ordered. The wound vac was not available in the facility, and the order for its use was eventually discontinued by the Wound Care Physician due to lack of availability. The initial wound assessments with measurements were only completed three days after admission, and wound care treatments began at that time. Interviews with facility staff, including the Unit Manager, Medication Aide, Wound Care Nurse, Wound Care Physician, and DON, confirmed that the initial wound assessments and wound care orders were not completed as required upon admission. The lack of timely assessment and initiation of wound care was attributed to the failure of the weekend nursing staff to perform these duties, the absence of a dedicated wound nurse at the time, and the unavailability of necessary wound care supplies. The Wound Care Physician noted that the resident's wounds worsened during the stay, with factors including missed wound treatments and inadequate offloading.