Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to provide adequate and timely pressure ulcer care for two residents, resulting in actual harm to one. For a resident with multiple comorbidities including diabetes and peripheral vascular disease, staff did not promptly assess a newly discovered open wound, nor did they notify the physician or obtain treatment orders in a timely manner. The wound was left unaddressed for several days, during which time it increased in size and severity, eventually being classified as a stage IV pressure ulcer. Even after wound care orders were obtained, staff did not consistently perform the ordered treatments, as evidenced by multiple missed dressing changes documented in the treatment administration records. Another resident, who was at high risk for skin breakdown and required total care, also did not receive timely wound assessments or treatments as ordered for a stage III pressure ulcer. There was a lack of documentation regarding wound assessments, measurements, and descriptions, and several ordered dressing changes were not completed. The facility's own policy required prompt physician notification and adherence to treatment orders, but these procedures were not followed for either resident. Interviews with the Director of Nursing confirmed the absence of required documentation and the failure to complete wound care treatments as ordered. The deficiencies affected two of three residents reviewed for pressure ulcers, with one resident experiencing actual harm due to the lack of timely intervention and ongoing missed treatments.