Failure to Timely Assess and Treat Pressure Ulcer on Admission
Penalty
Summary
Facility staff failed to thoroughly assess and implement timely interventions for the care of a pressure ulcer for one resident. Upon admission, the resident was noted to have an unstageable pressure ulcer on the right hip, but the initial assessment lacked a detailed description of the wound, including its size, appearance, condition of surrounding skin, and presence of drainage, odor, or pain. Daily skilled notes acknowledged the presence of the pressure ulcer but did not document any treatments or dressing changes. No comprehensive assessment or treatment orders were initiated for the pressure ulcer until five days after admission, when a wound nurse practitioner performed a thorough assessment and began appropriate wound care. The resident had multiple comorbidities, including congestive heart failure, atrial fibrillation, diabetes, obesity, and cognitive communication deficit, and was assessed as cognitively intact. Despite the presence of a pressure ulcer on admission and the absence of hospital-provided wound care orders, nursing staff did not contact the in-house provider, on-call provider, or wound nurse practitioner to obtain necessary treatment orders. Interviews with LPNs and the DON confirmed that no comprehensive wound assessment or treatment orders were documented prior to the wound nurse practitioner's intervention, and staff could not explain why appropriate actions were not taken when the wound was first identified. Facility policy required prompt reporting and documentation of changes in skin integrity, comprehensive wound assessments, and timely notification of providers for evaluation and treatment. These procedures were not followed, as evidenced by the lack of detailed wound assessment, absence of treatment orders, and failure to implement dressing changes for the pressure ulcer during the initial days after admission. The deficiency was confirmed through staff interviews, clinical record review, and facility policy review.