F0686

D

Failure to Initiate Timely Pressure Ulcer Treatments on Admission

St Mary Of The Woods, Indiana Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to initiate and provide timely pressure ulcer and wound treatments for multiple residents upon admission or when wounds were first identified. For Resident B, pre-admission screening and hospital discharge instructions documented a wound to the right buttock/coccyx with specific orders for Mepilex and barrier cream. However, the admission skin assessment did not document a buttock or coccyx wound, and the Treatment Administration Record (TAR) for November lacked evidence of any physician’s treatment orders for the buttocks or coccyx prior to several days after admission. Subsequent notes showed moisture-associated skin damage to the right buttock identified as acquired in-house and, later, a stage 3 pressure ulcer to the right inner buttock, with treatment orders not obtained until after these findings.

For Resident C, the admission MDS indicated an unhealed pressure ulcer, and nursing notes documented pressure ulcers on each buttock with physician notification. The resident was sent to the ER and later returned, with a skin check note indicating a buttock wound but lacking a detailed wound assessment or measurements. A physician’s order for cleansing and applying Medihoney with bordered gauze to bilateral buttock wounds was not obtained until days after the wounds were documented, and the December TAR lacked documentation of any treatment orders for these pressure ulcers prior to that date. A wound NP later documented two stage 3 pressure ulcers, one on each buttock, and recommended specific topical treatments.

For Resident D, a skin check documented moisture-associated skin damage to the buttocks at admission, and a wound NP note the following day identified a deep tissue injury to the sacrum that was present on admission. Despite this, the TAR for January showed no physician’s order for treatment of the sacral wound until a later date, when an order was finally written for cleansing, Triad cream, antifungal powder, and leaving the area open to air twice daily. In an interview, the DON confirmed she could not find documentation that wound treatments were initiated at the time of admission for these residents and stated that nurses should have followed hospital discharge instructions, notified the wound nurse, and obtained treatment orders at admission or when wounds were found. The facility’s policy required nurses to notify the attending physician and obtain treatment orders when new skin abnormalities were noted, but this was not done in these cases.