F0842

D

Incomplete and Inaccurate Documentation of Sacral Pressure Ulcer and Wound Care

Lakeside, Arizona Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a complete, accurate, and readily accessible medical record for a newly admitted resident with multiple complex wounds, including an unstageable pressure ulcer of the sacrum/coccyx. The resident was admitted with dementia, Alzheimer’s disease, osteomyelitis, sepsis, multiple diabetic foot ulcers, a pressure-induced deep tissue injury of the right heel, a nephrostomy tube, and an acquired absence of the left great toe. A weekly skin check and wound assessment documented numerous skin impairments, including a pressure injury on the sacrum, but did not provide details or measurements for that sacral wound. A care plan initiated on admission identified a pressure ulcer to the coccyx and called for weekly skin assessments and treatments as ordered, yet there was no corresponding, timely, or complete documentation of physician orders or wound treatments for the sacral/coccyx ulcer in the electronic medical record.

Handwritten paper documents created by the ADON, including a Treatment Plan and Evaluation of Care and a Formal Wound Assessment dated shortly after admission, described a sacral wound treatment regimen involving Santyl, oil emulsion dressings, zinc oxide as an alternative if the resident refused full treatment, and sacral dressings. These documents also referenced resident refusals of daily dressing changes and confusion. However, these handwritten records were not part of the electronic medical record, lacked a physician signature or order, and did not clearly document what wound care was actually provided on specific dates. The Formal Wound Assessment log noted refusals of wound assessments and treatment objectives on several days, but did not specify which treatments were refused or what, if any, care was completed. Late-entry notes by nursing staff documented that the resident refused “wound care” on multiple days without identifying which wounds or treatments were involved, and there was no evidence of documented education, multiple attempts, or provider notification regarding these refusals.

Physician orders in the record addressed wound vac care and wound care to the left foot and right heel but did not initially include any orders for treatment of the sacral/coccyx pressure ulcer. A pressure ulcer documentation assessment and related wound notes for the sacral wound were entered as late entries in early January, describing an unstageable sacral pressure ulcer measuring 4.3 cm by 5.2 cm with significant slough and exudate, and referencing daily Santyl treatments and zinc and sacral foam dressings, despite the absence of corresponding physician orders for Santyl or zinc at that time. The resident’s diagnosis list did not include a sacral pressure ulcer diagnosis until early January, and the admission MDS assessment documented no pressure ulcers or pressure ulcer care, even though the care plan already identified a coccyx pressure ulcer. Wound care to the coccyx did not appear on the treatment administration record until several days into January, after a physician order for coccyx wound care was finally entered. Interviews with nursing, MDS, and leadership staff confirmed inconsistent recognition and documentation of the sacral wound, reliance on separate handwritten wound records not integrated into the EMR, late entries due to the wound nurse being behind on paperwork, and a lack of clear, physician-ordered, and properly documented wound care for the sacral/coccyx pressure ulcer during the initial period after admission, contrary to facility policies on charting, skin/wound management, and physician orders.