Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely assessment, physician notification, and initiation of appropriate treatment for a pressure ulcer in one resident. According to the facility's policy, licensed nurses are required to conduct weekly skin integrity checks, document findings, and notify the physician to obtain treatment orders if a new wound is identified. On 1/17/25, an LPN documented an open wound with sanguineous drainage on a resident's left upper extremity and initiated first aid, but there was no documentation that the physician was notified or that treatment orders were obtained at that time. The Treatment Administration Record confirmed that no wound care treatment orders were in place from 1/17/25 until 1/22/25. Further review revealed that the wound was later assessed by a wound care physician on 1/22/25, who identified it as a Stage IV pressure ulcer requiring surgical debridement. Interviews with the LPN, the treatment nurse, and the DON confirmed that the physician was not notified when the wound was first identified and that treatment orders were not obtained until several days later. The resident involved had a history of hemiplegia and hemiparesis following a cerebral infarction and was cognitively intact at the time of the incident.