Failure to Identify and Document Intergluteal Cleft Wound
Penalty
Summary
The deficiency involves the facility’s failure to identify, assess, document, and report an open wound in a cognitively intact resident who was dependent on staff for all ADLs, including toileting and perineal care, due to bilateral arm fractures in hard casts. The resident’s EMR listed multiple traumatic fractures and functional dependence, and the MDS documented that the resident relied on staff for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. Despite this, the facility wound log did not include an open wound in the resident’s intergluteal cleft. The resident reported that he could not wipe himself and described episodes where staff found old stool during incontinence care, including an instance when a CNA applied cream to an area he described as red, open, bleeding, and very painful. The resident stated that on at least two occasions staff discovered old stool when he had not used the bathroom for several hours or since the prior day. On the date of the surveyor’s interview, the ADON, who oversees the wound program, stated she had not been aware of any skin alterations other than those related to the resident’s initial trauma and later learned from the resident that there had been an unreported open area in the intergluteal cleft that had never been assessed or treated. A CNA confirmed that during a shower she observed the resident’s buttock crease to be open, bleeding, and red, and that she applied an unknown cream from the resident’s room and informed an LPN, but there was no documentation of this wound in the record or on the wound log. The DON and ADON both stated staff should have documented the open area and notified the physician and the ADON per facility policy. The facility’s written policy required CNAs to observe for skin breakdown daily and on bath days, promptly report changes to the charge nurse, and required licensed nurses to initiate and document wound assessments for non-pressure skin conditions, with notification of the resident, representative, and physician at the earliest sign of skin problems. These required assessments, documentation, and notifications did not occur for this resident’s intergluteal cleft wound.
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