Failure to Timely Assess and Treat Newly Identified Pressure Ulcers
Penalty
Summary
The facility failed to ensure that newly identified pressure ulcer wounds were comprehensively assessed and that wound care orders were obtained and implemented for a resident with a diagnosis of osteomyelitis of the vertebrae. After admission, a CNA notified an LPN of an open sore on the upper part of the resident's buttock. The LPN observed, cleaned, and covered the wound, and initiated a Skin Integrity Report, but did not measure the wound, obtain provider orders, document wound treatment, or initiate any wound care protocol on the Treatment Administration Record (TAR) at that time. There was no evidence in the health record of a comprehensive wound assessment, including measurement, location, stage, or other characteristics, between the initial identification of the wound and two days later. Wound care orders were not obtained until two days after the wound was first identified, and wound care was not provided until the following day. The Director of Nursing Services confirmed that the wound was not comprehensively assessed and measured until two days after it was first identified, and that there was no evidence of wound care being provided during that period. This lapse in timely assessment and intervention did not follow the facility's protocol or national guidelines for pressure ulcer care.