Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. In the first case, a resident with a history of cerebral vascular accident and diabetes mellitus was admitted without pressure ulcers and was care planned for risk of impaired skin integrity. Despite this, no skin assessments were documented from admission onward. When a pressure ulcer was first identified on the resident’s right heel, there was no documented assessment or treatment order, and the wound was not reported to the medical director. The wound worsened over several days, eventually becoming unstageable with black eschar and foul odor before appropriate treatment and assessment were initiated. In the second case, another resident with multiple sclerosis and hemiplegia was identified as being at risk for pressure ulcers but did not receive routine skin assessments. When a stage 2 pressure ulcer was found on the back of the resident’s right thigh, the initial wound was not measured until several days later, and there was no ongoing assessment or documentation after the initial measurement. The treatment order for the wound was only in place for seven days and was not renewed, leaving the wound without further treatment orders or follow-up. The wound care nurse was not aware of the wound, and the wound was not followed by the wound care provider. Both cases revealed a lack of routine and systematic skin assessments by nursing staff, reliance on nurse aides to report skin issues, and inconsistent use of wound care standing orders. There was also a lack of communication and documentation regarding new wounds, failure to notify providers in a timely manner, and inadequate follow-up and monitoring of existing wounds. These deficiencies resulted in pressure ulcers going untreated for extended periods and worsening in severity.