F0686

D

Failure to Identify and Assess Coccyx Pressure Injury Before Progression to Stage III

Itasca, Illinois Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The facility failed to identify and assess a pressure wound before it progressed to a Stage III pressure injury for one resident. On admission/readmission skin assessment dated 12/17/25, the resident was documented as having no open areas or skin breakdown. A weekly wound evaluation on 12/18/25 noted blanchable redness to the buttocks with no open areas and no redness or open areas to the coccyx. Despite this, a later weekly wound evaluation dated 1/2/26 documented that a Stage III, in-house acquired pressure injury to the coccyx had been found on 12/30/25, with moderate thin, watery, serous drainage, yellow slough, and a resident pain rating of eight. A wound physician’s note dated 12/30/25 also documented a Stage III coccyx pressure wound reported on that date.

During observation on 1/17/26, the wound care nurse was seen providing treatment to the resident’s coccyx, which had an open area, while the buttocks showed no redness or open areas. The wound care nurse stated that the coccyx wound was first identified on 12/30/25 as a Stage III pressure wound, confirmed it was acquired in the facility, and acknowledged uncertainty about why it had not been found sooner. She also stated that healing was initially difficult because the resident did not like the low air loss mattress and only moved when staff moved him. A CNA reported that it is important to inform the wound care nurse and floor nurse immediately about any changes in residents’ skin. The resident’s Braden Scale assessments on multiple dates all showed the resident as low risk, and the facility’s pressure injury prevention guidelines require early risk identification and immediate reporting of new skin concerns or painful skin areas to the nurse for assessment.