Delayed Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when staff failed to timely initiate treatment for pressure ulcers in a resident with multiple medical conditions, including a stage four pressure ulcer, stroke, liver cirrhosis, and depression. The resident was admitted with deep tissue injuries to the left heel and left outer ankle, both measuring two centimeters in length and width, but the depth was not measured. Although physician orders to cleanse the wounds and apply skin prep every shift were written on the third day after admission, treatment was not started until that time, resulting in a delay of care. Staff confirmed that the prescribed treatment for the pressure ulcers was not initiated upon admission, despite the resident's dependence on staff for activities of daily living and severely impaired cognition. Online clinical guidance indicates that immediate treatment is required once a pressure ulcer develops.