Failure to Complete Significant Change Assessment After Development of Stage Four Pressure Ulcer
Penalty
Summary
The facility failed to initiate a significant change in status assessment (SCSA) for a resident who developed a stage four pressure ulcer to the sacrococcyx. The resident, admitted with Guillain-Barre Syndrome and adult failure to thrive, was found to have a stage four pressure ulcer as documented in multiple wound care consult notes. Despite the presence of this severe wound, which was being treated per physician orders, the required SCSA was not completed within the mandated timeframe after the ulcer was identified. During interviews and record reviews, the MDS Coordinator confirmed that the SCSA was not performed and acknowledged that it should have been initiated 14 days after the wound was established. The Director of Nursing stated that it was her expectation for MDS assessments to be completed properly and on time. Facility policy also required a comprehensive assessment following a significant change in a resident's condition, in accordance with OBRA regulations, but this was not followed in this case.