Failure to Accurately Assess and Timely Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure comprehensive and accurate pressure ulcer assessments, timely implementation of treatments, and adherence to pressure-relieving interventions as outlined in the care plan for a resident with multiple comorbidities, including a right femur fracture, chronic kidney disease, anemia, diabetes, protein-calorie malnutrition, dementia, heart disease, venous insufficiency, and a pressure ulcer. Upon re-admission, the resident was identified as having a suspected deep tissue injury on the sacrum, but there was no documented evidence that the physician was notified or that the wound nurse was consulted until more than a month later. Additionally, a pressure-reducing cushion was ordered, but observations revealed the resident was using an inadequate cushion, and staff confirmed it was not a proper pressure-relieving device. Medical record reviews showed inconsistent and incomplete documentation of the resident's skin condition. Weekly skin observations and skin grid assessments often lacked detailed descriptions of the wounds, including stage, drainage, odor, and other required characteristics. Several weekly pressure ulcer assessment forms were not completed, and the non-pressure forms used did not provide comprehensive information or proper staging. The resident's MDS assessment was also found to be inaccurate, failing to reflect the presence of a pressure ulcer on admission. There was a significant delay in implementing treatment for the sacral area, with no evidence of any treatment from the time the wound was identified until nearly two weeks later. The wound nurse did not assess the pressure ulcer until a telehealth visit was conducted, and the physician's progress notes did not mention or assess the pressure ulcer during the relevant period. Facility policy required prompt notification of the physician and responsible party, comprehensive documentation, and regular assessment, but these procedures were not followed as evidenced by the findings.