Failure to Identify and Obtain Orders for Pressure Ulcer
Penalty
Summary
The facility failed to appropriately identify and manage a pressure ulcer for a resident who was admitted without any pressure ulcers. Upon admission, the resident's care plan did not indicate any open areas or non-blanchable redness to the sacrum or buttocks. However, a subsequent nursing note documented a new skin condition involving a small skin tear with non-blanchable redness to the sacrum/buttocks. The nurse cleansed the area and applied a zinc barrier cream with a bordered gauze, but there was no documentation that the physician was notified or that a treatment order was obtained for the new wound. Further review of the Treatment Administration Record showed no evidence of ongoing assessment, care, or monitoring for the identified wound. During a later observation, the resident was found to have a pressure ulcer measuring approximately 1.5 cm by 1.0 cm on the left medial sacrum. Interviews with nursing staff revealed that the nurse who initially identified the wound assumed the Resident Care Manager would notify the physician and obtain an order, but this did not occur. The Director of Nursing confirmed that there was no investigation into the cause of the injury and was unable to provide documentation of such an investigation.