F0684

D

Failure to Assess and Notify Provider for New Sacral Pressure Ulcer

Cortland, New York Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and its own policies when a resident developed a new sacral pressure ulcer. The resident had multiple diagnoses including type 2 diabetes mellitus with complications, cellulitis of the left great toe, and a history of a stage 3 sacral pressure ulcer. Admission and subsequent assessments documented intact skin, and the care plan included weekly skin checks, incontinence management, pressure-reducing devices, and other skin integrity interventions. Prior to the incident, there were no physician orders for pressure ulcer treatment, and the resident was documented as not having unhealed pressure ulcers and not being at risk for pressure ulcers on the most recent MDS, despite other documentation indicating they were at risk.

On the night shift of 12/26–12/27, a CNA observed a skin issue on the resident’s sacrum and notified an RN, who assessed the area as red and quarter-sized, cleansed it with normal saline, and applied a foam dressing. The RN did not document this assessment in the nursing progress notes and did not notify a medical provider, contrary to facility policy requiring assessment and physician notification for changes in condition. The RN reported the issue only to the oncoming nurse at shift change. The following day, a CNA on day shift again observed a reddened area on the sacrum and a soiled, detached dressing in the resident’s incontinence brief, and notified an LPN. The LPN applied a clean foam dressing and notified an off-duty RN unit manager by text, rather than the in-house nursing supervisor, and did not contact a medical provider. The RN unit manager, who was not in the building, instructed that a progress note not be written until an RN assessed the area, and no further direction was given.

Later that same day on evening shift, another LPN reported to the RN supervisor that the resident had a change in condition, including a blood sugar of 504 and a pressure area on the sacrum. Upon removing the foam dressing, the RN supervisor found the sacral wound to be foul-smelling with gray and brown drainage and documented low oxygen saturation and an elevated temperature. The on-call medical provider was then notified and ordered the resident sent to the emergency department. Hospital documentation later identified the sacral wound as an unstageable pressure ulcer requiring packing and as a stage 3 decubitus ulcer. There was no documented RN assessment or provider notification at the time the sacral wound was first identified or during the subsequent day shift, and no Braden reassessment was completed when the ulcer was discovered, despite facility policy requiring such actions when a new pressure injury or change in condition occurs.

Interviews confirmed that the physician assistant who last saw the resident before the ulcer was discovered had not been informed of any skin issues and had observed intact skin at that time. The assistant DON/wound nurse stated they were not notified of the sacral ulcer until the resident was readmitted from the hospital and that a Braden assessment should have been completed when the ulcer was first found. The DON stated that nurses who discover a skin issue are expected to notify the nursing supervisor and medical provider, obtain treatment orders, and, if the nurse is an LPN, ensure an RN assessment occurs or contact leadership if no RN is in the building. The facility’s own investigation concluded that the night-shift RN who first assessed the sacral area did not document the pressure area or notify a medical provider, and that both the night RN and the day-shift LPN failed to follow the required notification chain of command, resulting in a lack of timely assessment and provider notification for the new sacral pressure ulcer.