Delayed Wound Care and Physician Notification for Pressure Ulcers
Penalty
Summary
The facility failed to provide timely wound care and physician notification for a resident who developed skin impairments on both ankles. The resident, admitted after a fall and with diagnoses including rhabdomyolysis, left quadricep injury, and right peroneal nerve compression, initially had no skin impairments noted on admission. The care plan included interventions such as frequent repositioning, use of a pressure reduction mattress, and monitoring for skin issues. On November 30, a small open area was observed on the left ankle and redness on the right ankle; the area was cleaned and dressed, but there was no documentation that the physician was notified of these findings at that time. Further review showed that the physician was not notified of the skin impairments until December 3, and no wound treatments were documented for the bilateral ankles on December 1, 2, or 3. On December 3, a wound NP assessed the resident and identified a deep tissue pressure injury on the left ankle and an unstageable pressure ulcer with eschar on the right ankle, ordering specific wound care. However, the ordered treatment was not initiated until December 5, two days after the order was made. Staff interviews confirmed the delays in both physician notification and initiation of wound care treatment.