Failure to Assess and Treat Pressure Injury on Admission
Penalty
Summary
Facility staff failed to provide appropriate care and services for a pressure injury for one resident. Upon admission, the resident was documented as having an open wound on the sacrum, but the assessment lacked further descriptors such as measurements, stage, or wound characteristics. Although a physician's order was entered to cleanse the wound and apply a foam dressing, this order was not reflected in the medication or treatment administration records due to a scheduling error in the computer system. As a result, there was no evidence that the prescribed treatment was provided for three consecutive days. During this period, daily skilled assessments incorrectly indicated that the resident did not have impaired skin or a wound being monitored or treated. A subsequent body audit identified a stage three pressure injury on the sacrum, with specific measurements documented. Staff interviews confirmed that wound assessments and treatments are typically communicated and documented via the treatment administration record, but this process failed in this instance, leading to a lack of timely and appropriate wound care.