Failure to Identify and Care Plan for Pressure Injury on Admission
Penalty
Summary
The facility failed to identify, treat, and care plan for a pressure injury for one resident who was admitted with a right ankle fracture and a red, non-blanchable soft mass on the middle of the back. Upon admission, the area met the definition of a Stage I pressure injury, but there was no documentation of provider notification, treatment orders, or wound care planning. The nurse who completed the admission did not inform the wound care nurse or provider about the non-blanchable area, and no treatment orders were obtained. The resident's care plan only indicated a risk for pressure injuries, without addressing the existing wound. Subsequent documentation showed that the wound was not assessed by an RN after admission, was not monitored weekly, was not added to the treatment administration record (TAR), and the provider and RN were not notified. Later progress notes documented an abrasion and, eventually, an unstageable pressure injury at the same site, but there was no investigation into the progression or cause of the wound. Facility leadership confirmed that required assessments, monitoring, and care planning were not completed for the pressure injury.