Failure to Timely Assess and Treat Newly Identified Pressure Ulcers
Penalty
Summary
The facility failed to ensure that newly identified wounds for a resident were promptly assessed, measured, and treated according to policy. Medical record review showed that a resident with multiple diagnoses, including spastic diplegic cerebral palsy, chronic kidney disease, and chronic respiratory failure, was at risk for pressure ulcers and had a care plan in place for impaired skin integrity. On several occasions, documentation indicated the presence of open sores on the resident's buttocks, but there was no evidence of wound assessment, measurement, or detailed description in the records. Orders for barrier cream were present, but the wounds were not properly evaluated or described until a wound physician assessment was completed nearly two weeks after the initial identification of the sore. Staff interviews confirmed that wound measurements and descriptions were not completed when new wounds were found, and the physician was not notified in a timely manner. Facility policy required prompt identification and management of skin complications, but this was not followed. The deficiency was identified through medical record review, staff interviews, and policy review, and affected one resident out of three reviewed for pressure ulcers.