Failure to Timely Assess and Stage Pressure Ulcers on Admission
Penalty
Summary
The facility failed to properly assess, stage, and provide timely wound care interventions for pressure ulcers in two residents. For one resident, the initial admission assessment documented a rash on the sacrum, but this was later staged as a Stage II pressure ulcer nearly two months after admission. The initial assessment did not include measurements, and the wound was not staged until much later by a nurse and nurse practitioner. The resident's care plan and treatment orders were not updated promptly, and there were missed treatments according to the treatment administration record. Interviews with nursing staff revealed confusion and delays in wound assessment and staging, with reliance on the wound nurse practitioner for staging and evaluation, which did not occur in a timely manner. Another resident was admitted with a history of diabetes mellitus and an existing wound on the right hip. The initial admission assessment did not properly identify or stage the wound, which was later determined to be a Stage III pressure ulcer by the wound nurse practitioner over two weeks after admission. The initial assessment described the wound but did not confirm its stage, and the resident did not have appropriate pressure-relieving devices in place. The resident reported not being turned while in bed, and the wound nurse practitioner did not assess the wound until well after admission, resulting in delayed interventions. Record reviews and staff interviews indicated that registered nurses responsible for admission assessments either did not stage wounds or deferred staging to the wound nurse practitioner, leading to delays in care. The facility's policy required examination of newly admitted residents for pressure ulcers, but this was not consistently followed. The minimum data set (MDS) assessments were also inaccurately coded due to reliance on delayed or incomplete documentation, further contributing to the delay in appropriate wound care and interventions.