Failure to Timely Initiate Pressure Ulcer Treatment on Admission
Penalty
Summary
The facility failed to ensure timely initiation of skin care treatments for a resident who was admitted with a pressure ulcer. Upon admission, the resident had multiple diagnoses including hypertension, type 2 diabetes mellitus with diabetic neuropathy, peripheral vascular disease, and congestive heart failure. The resident was cognitively impaired and required supervision or minimal assistance with daily activities. Medical records indicated that the resident was at risk for pressure ulcers and had an unstageable deep tissue injury present on admission, but there was no documentation of pressure ulcer care, dressings, or topical ointments in the initial care plan or hospital discharge orders. Weekly skin and wound assessments documented the presence and progression of the pressure ulcer, including measurements and descriptions of the wound. Although a treatment plan for a zinc-based barrier cream was noted in the assessment, there was no evidence that this treatment was ordered or administered. The medication and treatment administration records for the relevant months were silent regarding wound care orders until several days after admission, when orders for wound gel and dressings were finally initiated. The wound nurse practitioner was notified and evaluated the wound, recommending specific treatments and interventions, but these were not implemented until after a delay. Staff interviews confirmed that the facility did not have documentation of the prescribed barrier cream being applied as indicated in the assessment, and that wound care orders were missed upon admission. The LPN verified that there were no wound care orders in the medication or treatment records until well after the resident's admission, resulting in a lack of timely wound care for the resident's pressure ulcer.