Failure to Initiate Timely Treatment and Documentation for New Pressure Ulcer
Penalty
Summary
The facility failed to follow its own Skin Integrity and Wound Management policy after a new pressure ulcer was observed on a resident's right big toe. Although the policy required nursing assistants to observe and report skin changes daily and for licensed nurses to evaluate, document, and initiate treatment for new wounds, these steps were not followed. The wound was first identified on the resident's right big toe, but no treatment or monitoring was started for eight days. Documentation in the clinical record on two occasions after the wound was present did not mention the wound, and no treatment orders were initiated during this period. Interviews revealed that staff were either unaware of the wound or assumed it was already being addressed due to another wound on the resident's left toe. A photo of the right big toe wound was taken by a nurse, but it was not entered into the clinical record, and no further documentation or action was taken. The wound was ultimately brought to the attention of nursing staff by a family member and a surveyor, at which point the facility acknowledged that the required process for wound identification, documentation, and treatment had not been followed.