Failure to Initiate Timely Wound Care for Admitted Resident With Sacral Pressure Ulcer
Penalty
Summary
Facility staff failed to initiate and document pressure ulcer treatment for a newly admitted resident with a known sacral pressure injury for four days following admission. The resident was admitted with type 2 diabetes, severe cognitive impairment, dependence on staff for hygiene, mobility, and transfers, and an unstageable sacral pressure ulcer documented as present on admission. The admission MDS and skin assessment identified the sacral pressure ulcer and noted a clean, dry dressing, but the skin assessment did not include wound measurements. Review of the medical record and Treatment Administration Record (TAR) showed no wound care orders or documented sacral wound treatment on the four days immediately following admission. On a later date, a wound care order was entered on the TAR for daily cleansing of the sacrum and application of medical grade honey for a Stage 3 pressure injury, and this order was then discontinued and replaced the same day with a new order for cleansing, Santyl, and quarter-strength antimicrobial-moistened gauze for an unstageable pressure injury. Interviews with the former Wound Treatment Nurse, Corporate Nurse Consultant, Medical Director, and Wound PA confirmed there was no evidence that wound care orders had been implemented or that staff had contacted a provider or the wound care company for wound treatment orders during the four-day gap after admission, despite standing orders that required MD or wound specialist orders for Stage 3 and 4 wounds. The Wound PA noted that weekly wound evaluations began only after the initial wound consult, and there was no documentation that facility staff had reached out to the consulting company prior to that evaluation.
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