Failure to Initiate Timely Pressure Ulcer Treatment and Documentation
Penalty
Summary
A resident admitted in November 2025 with a history of laminectomy, diabetes mellitus, and obesity was found to have a Stage 2 pressure ulcer on the coccyx and popped blisters in the same area upon admission. The initial skin assessment documented the presence of these wounds but did not include measurements or a detailed description. There was no evidence that a treatment order for the wounds was obtained or implemented at the time of admission. Review of the clinical record and staff interviews confirmed that the resident's wound was not treated for six days following identification. The admitting nurse acknowledged failing to obtain a treatment order upon admission, and the wound nurse confirmed that standard practice requires a complete assessment and prompt initiation of treatment orders for identified wounds. Documentation did not show that the resident received any wound care from the time the wounds were first identified until six days later.