F0686

D

Failure to Initiate and Document Timely Pressure Ulcer Treatment on Admission

Scottsdale, Arizona Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely and complete pressure ulcer care and assessment for a resident admitted with an existing coccyx wound. The resident was admitted with multiple comorbidities, including a left tibia fracture, type II diabetes with hyperglycemia, pulmonary fibrosis, shortness of breath requiring oxygen, and bowel and bladder incontinence. An admission Braden scale showed a score of 15, and a progress note on the admission date documented a stage 4 coccyx ulcer with foul odor. The care plan identified existing and at-risk skin areas, including the coccyx, and called for treatments as ordered, weekly skin assessments, and adherence to facility policies for prevention and treatment of skin breakdown. A physician order for weekly skin checks was also in place.

Despite the identification of a stage 4 coccyx ulcer on admission, the weekly skin check and wound assessment note for that date did not include required wound descriptors such as measurements, odor, drainage, tunneling, or description of surrounding skin and wound edges/bed. The clinical record showed no evidence that any wound treatment was initiated on the admission date, and there was no documentation of wound care being provided until two days later. On the subsequent weekly skin check, the coccyx wound was documented as an unstageable pressure ulcer present on admission, with specific measurements, drainage, odor, necrotic tissue, and surrounding slough, and treatment orders including Medihoney, alginate, and foam dressing were documented at that time. A low air loss mattress was requested, and an order for an air mattress and specific wound care regimen was entered and transcribed onto the treatment and wound administration records on that later date.

Interviews with facility staff confirmed that the documented practice did not align with facility expectations and policy. The MDS nurse and an RN stated that upon admission, a head-to-toe skin assessment is performed, the provider is notified for orders if a wound is identified, and treatment is expected to begin as soon as orders are received, with each treatment documented; they both indicated that if there is no documentation, the treatment is considered not done, and that a delay of two to three days in treatment would not meet expectations. The DON stated that nurses are expected to assess and document wound characteristics on admission, transcribe any existing wound orders, and notify the provider if no orders exist, and that wound care documentation must include details of the care provided and resident response. The DON and corporate resource both acknowledged that they found no documentation that wound treatment was provided to this resident prior to the later date. The facility’s written policy required full assessment and documentation of pressure ulcers, including location, stage, size, exudate, necrotic tissue, pain, mobility status, current treatments, and support surfaces, and required that newly admitted residents be examined for existing pressure ulcers so that the physician could order appropriate wound treatments and pressure reduction surfaces, which was not fully carried out for this resident on admission.