F0686

D

Failure to Obtain and Implement Timely Physician-Ordered Care for Sacral Pressure Ulcer

Lakeside, Arizona Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely assess and treat a sacral/coccygeal pressure ulcer and to obtain and implement physician-ordered treatment for that wound. A resident was admitted with multiple serious conditions, including dementia, osteomyelitis, sepsis, diabetic foot ulcers, a right heel deep tissue injury, and a history of left great toe amputation. On admission, a weekly skin check and wound assessment documented multiple wounds, including a pressure injury on the coccyx/sacrum, and the care plan initiated the same day identified a pressure ulcer to the coccyx with interventions such as pressure-relieving mattress, weekly skin assessments, and monitoring and reporting changes. An audit of the skin assessment showed that an LPN initially documented a pressure injury on the coccyx, which was later edited by the ADON/RN to indicate a pressure injury on the sacrum. Despite this, there was no corresponding physician order in the electronic record for wound care to the coccyx/sacrum at admission or in the days immediately following.

Handwritten paper documents created by the ADON, including a Treatment Plan and Evaluation of Care dated the day after admission and a Formal Wound Assessment log, described cleansing the sacral wound, applying Santyl, oil emulsion, skin prep, sacral dressing, and zinc oxide if full treatment was refused, and referenced enzymatic debridement and sacral foam protection. These documents also contained notations about the resident refusing daily changes and being confused, and later entries indicated refusals of wound assessment and treatment on several consecutive days. However, these handwritten records were not part of the electronic medical record, did not show clearly what wound care was actually performed, and there was no evidence of a physician order for Santyl, zinc, or specific sacral dressing changes during that period. The facility’s standing wound orders did not include Santyl, and the ADON, who lacked prescriptive authority, stated she believed she had told the physician about her treatment recommendations but there was no documented provider order. Late-entry notes by nursing staff documented that the resident refused wound care on multiple days, but did not specify which wounds or treatments were refused, and there was no documentation of resident education, multiple attempts, or provider notification regarding these refusals.

Further documentation inconsistencies contributed to the deficiency. A Pressure Ulcer Documentation assessment for the sacral wound, showing an unstageable ulcer measuring 4.3 cm by 5.2 cm with significant slough and moderate exudate, was created and signed more than a week after the admission date and described the visit as an initial assessment. Another pressure ulcer assessment created later again documented the same unstageable sacral ulcer with similar measurements and noted zinc and sacral foam dressings and that new orders for daily Santyl were placed, yet no corresponding physician order was found in the clinical record for that date. The admission MDS, completed by the MDS coordinator using EMR data, recorded that the resident had no pressure ulcers and no pressure-ulcer care, despite the care plan and nursing documentation indicating a coccyx/sacrum pressure ulcer. The MDS coordinator acknowledged that the pressure ulcer appeared to have been missed. Review of the MAR/TAR showed no sacral/coccygeal wound treatments documented for the remainder of the admission month and into the following month until a physician order for coccyx wound care, including Santyl and specific dressing steps, was finally entered with a start date nearly two weeks after admission, and treatments to the coccyx began on that start date. Interviews with nursing staff, the ADON, and the DON confirmed that the resident had an unstageable sacral pressure ulcer on admission, that the ADON kept separate handwritten wound records, that floor nurses did not consistently recognize or document the sacral wound, and that the DON relied on standing wound orders despite the absence of specific physician orders for the sacral pressure ulcer treatment.

The facility’s own policies required full assessment and documentation of pressure ulcers, including measurements and exudate description, and required that wound treatments and topical agents be ordered by a physician or other authorized prescriber and recorded as written, dated, and signed orders. Policies also required that wound care documentation include the type of wound care given, date and time, resident position, staff performing the care, changes in condition, and detailed assessment data. In this case, there was no evidence of timely, complete sacral wound assessment in the EMR at admission, no timely physician orders for sacral wound treatment, incomplete and delayed documentation of the sacral pressure ulcer, and missing or nonspecific documentation of wound care actually provided. The combination of undocumented or late-entered assessments, lack of provider orders for Santyl and other sacral treatments, inaccurate MDS coding omitting the pressure ulcer, and absence of MAR/TAR entries for sacral wound care until well after admission constituted the actions and inactions that led to the cited deficiency in providing appropriate pressure ulcer care and preventing further ulcer development.

The facility’s standing orders and wound care policies were reviewed and showed that while standard wound preparation, cleaning, and non-sharp debridement techniques were authorized, the use of prescription enzymatic debridement agents such as Santyl required a specific provider order, which was not present for the sacral wound during the relevant period. The ADON’s reliance on handwritten treatment plans and separate wound logs, not integrated into the EMR and not supported by provider orders, further contributed to the lack of clear, timely, and authorized treatment for the sacral pressure ulcer. Interviews with staff revealed confusion about the presence and location of the sacral wound, with at least one LPN stating he did not believe the resident had sacral wounds, and the DON acknowledging that terms like coccyx and sacrum were used interchangeably, which may have affected documentation clarity. Collectively, these documented failures in assessment, physician ordering, EMR documentation, and implementation of wound care for the sacral pressure ulcer formed the basis of the deficiency.