Failure to Timely Assess and Treat New Pressure Ulcer
Penalty
Summary
A resident with diagnoses including heart failure and weakness, and who was assessed as being at risk for skin breakdown, developed a new unstageable pressure ulcer on the left heel. The wound was first observed by a certified nurse aide, who reported it to an LPN. The LPN then reported the wound to the registered nurse supervisor. Despite these notifications, there was no documentation of the wound, no assessment performed by licensed staff, and no treatment order was implemented at the time the wound was discovered. The facility's policy required timely and appropriate assessment, intervention, and documentation of skin issues, as well as prompt notification to the attending practitioner and other relevant healthcare professionals. However, after the wound was initially identified, there was a lapse of approximately two weeks during which the wound was neither assessed nor treated. Staff interviews confirmed that the wound was reported up the chain of command, but no further action was taken, and the wound was not documented in the resident's medical record. The LPN involved acknowledged that they did not document the wound and should have done so, while the registered nurse supervisor did not recall the incident and there was no evidence of their assessment or follow-up. It was only after the former Director of Nursing became aware of the wound that an investigation was initiated, the wound was assessed, and a treatment order was obtained. The delay in assessment and treatment was confirmed by staff statements and facility investigation, which concluded that the resident did not receive timely care for the pressure ulcer. The lack of documentation, assessment, and prompt intervention was inconsistent with professional standards of practice and the facility's own policies.