Failure to Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly assess, monitor, and treat pressure ulcers for a resident admitted with significant risk factors, including end stage kidney disease, diabetes, decreased mobility, and incontinence. Upon admission, the resident was noted to have an unstageable sacral wound, but no comprehensive assessment was performed to document the wound's characteristics such as location, stage, measurements, tissue type, or other relevant details. There was also no evidence that the facility provider was notified of the wound, and no wound care or treatment was documented for the first six days following admission. Additionally, after the resident was hospitalized and returned with specific wound care orders for the sacrum and both heels, the facility failed to initiate or document the prescribed treatments in a timely manner. Treatment for the sacral wound was delayed by five days, care for the left heel was delayed by thirteen days, and there was no record of treatment for the right heel wound. Interviews with staff revealed confusion and lack of clarity regarding responsibilities for wound assessment, documentation, and initiation of care orders. Staff acknowledged that required assessments and treatments were not completed as expected, and the resident's wound condition did not improve during their stay.