Failure to Timely Assess and Treat Pressure Ulcer on Readmission
Penalty
Summary
The facility failed to assess and implement timely treatment for a pressure ulcer on a resident's right heel. Upon the resident's return from a hospital stay, the initial skin assessment by the wound care nurse only documented a pre-existing sacral wound, and no other areas were noted. This note was later struck out and replaced with a late entry indicating the presence of an unstageable pressure area on the right heel, which was present upon the resident's return. Despite the wound nurse being aware of the right heel pressure area, there was a delay in obtaining and implementing treatment orders, as the nurse waited for an outside Nurse Practitioner to assess the wound before proceeding. Documentation inconsistencies were also noted, including backdating of assessments and inaccurate reporting of when new orders were obtained. Interviews with staff revealed confusion and lack of clarity regarding the assessment and documentation process. The LPN who performed the readmission assessment relied on the wound nurse's assessment, which initially failed to identify the right heel wound. The Director of Nursing confirmed that the facility's expectation was for immediate notification and order acquisition upon discovery of abnormal findings, and that documentation should not be backdated. Facility policy required examination and documentation of skin alterations at admission, but this protocol was not followed in this case, resulting in a delay in treatment for the resident's pressure ulcer.