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F0686
D

Failure to Accurately Assess and Obtain Orders for Pressure Ulcers

Kittanning, Pennsylvania Survey Completed on 07-01-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately assess pressure ulcers for one of three residents, as required by facility policy and national guidelines. According to the clinical admission assessment, the resident had a stage 2 pressure ulcer on the coccyx, an unstageable pressure ulcer on the right medial ankle, and a blister on the left heel. Despite these findings, there were no physician orders for the treatment of these skin impairments until several days after admission. The Director of Nursing confirmed during an interview that the facility did not perform accurate assessment of the pressure ulcers as required. The resident's medical history included thrombophilia, chronic embolism, and rhabdomyolysis.

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