Failure to Timely Assess and Treat Pressure Ulcers on Admission
Penalty
Summary
The facility failed to complete pressure ulcer assessments upon admission and did not timely initiate treatment for pressure ulcers for one resident. Upon admission, the resident had multiple medical diagnoses, including aftercare following surgical amputation, peripheral vascular disease, end stage renal disease, and diabetes mellitus. The initial nursing comprehensive assessment documented the presence of a right toe amputation and redness to the buttocks, coccyx, and heels, but did not include measurements or detailed descriptions of these skin issues. Wound and skin evaluations were not completed until five days after admission, at which point multiple wounds were identified and measured, including vasculitic injuries, deep tissue injuries (DTIs), and moisture-associated skin damage. However, there was no documentation that treatment for these wounds was initiated until the day after the evaluation was completed. Staff interviews and policy review confirmed that the facility's policy required a baseline total body skin evaluation and prompt initiation of appropriate interventions and physician orders for any skin impairments upon admission. The medical record lacked evidence that these requirements were met for the resident in question, as wounds were not evaluated or treated in a timely manner. The deficiency was identified during a complaint investigation and was based on the facility's failure to follow its own skin management policy for new admissions with existing skin impairments.