Failure to Timely Assess and Initiate Treatment for Wounds Upon Admission
Penalty
Summary
The facility failed to complete wound assessments at the time of admission and did not timely initiate treatment for wounds for two out of three residents reviewed. For one resident with multiple medical conditions including diabetes, peripheral vascular disease, and a recent amputation, the admission assessment noted several skin issues but did not include measurements or detailed descriptions. Comprehensive wound evaluations were not completed until five days after admission, and physician-ordered treatments were not initiated until six days after admission. The resident was subsequently seen weekly by a wound physician, but initial documentation and intervention were delayed. Another resident admitted with a history of diabetes and chronic foot ulcers also did not have wound measurements or descriptions documented at admission, despite having visible surgical wounds. Although a physician order for wound care was obtained the day after admission and treatments were administered as ordered, the wounds were not measured or fully assessed until five days post-admission. Staff interviews confirmed the lack of timely wound assessment and documentation. Facility policy required baseline total body skin evaluations and prompt documentation of wound characteristics and interventions upon admission, which was not followed in these cases.