Failure to Identify and Treat Facility-Acquired Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to identify, assess, and implement treatment orders for a resident who developed a facility-acquired pressure ulcer. The resident, who had risk factors such as impaired mobility, bowel incontinence, and peripheral vascular disease, reported pain and a sore on his right buttock to staff approximately two weeks prior to the survey. Despite the resident's report and a previous order for barrier cream, no dressing or cream was being applied, and the resident stated that nothing had been done after he informed staff. During observation, an open area was found on the resident's right buttock with no treatment in place, and the wound nurse was unaware of the open area until the day of the survey. Further review revealed that the barrier cream ordered for the resident was not present in his room, and there was no documentation in the electronic health record regarding the skin alteration. The wound nurse was unable to locate wound notes for the previously identified skin issue, and the care plan, while noting the potential for pressure ulcer development and interventions, was not being followed as treatments were not administered as ordered. The facility's policy requires prompt identification, documentation, and treatment of skin breakdown, but these steps were not carried out for this resident.