F0686

D

Failure to Assess and Care Plan Newly Developed Coccyx/Buttock Wound

Bay Village, Ohio Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to comprehensively assess a newly identified skin alteration on a resident’s sacral/buttock area and to timely revise the resident’s care plan for pressure ulcer prevention and treatment. The resident was admitted with multiple medical diagnoses, including senile degeneration of the brain, emphysema, heart block, obstructive and reflux uropathy, hyperlipidemia, heart failure, and atrial fibrillation. On admission, the resident had no pressure areas but did have scattered bruising, abrasions, scabs, and a surgical incision. A Braden Scale assessment completed on the day of admission showed a score of 12, indicating high risk for skin breakdown, with findings of very limited sensory perception, very moist skin, chairfast status, very limited mobility, probably inadequate nutrition, and a potential problem with friction and shear. A nutrition assessment documented that the diet was adequate and that the resident was at risk for skin breakdown but had no identified pressure ulcers. An MDS assessment confirmed no pressure ulcers and total dependence on staff for ADLs, with an indwelling urinary catheter and bowel incontinence.

On a later date, the resident sustained an unwitnessed fall. An LPN found the resident on the floor sitting on his bottom, and the resident reported pain in that area. The LPN documented an injury on the coccyx described as a skin tear and redness, and the facility’s fall report listed a bruise to the coccyx, a bruise to the right cheek, and a skin tear to the coccyx. Weekly wound documentation for the right buttock and coccyx on the date of the fall recorded bruising measuring 4.5 cm by 2.6 cm with a wound bed described as 100% purple, and a skin tear to the coccyx without measurements or further description of the periwound area. There was no evidence in the medical record that the skin tear was fully measured and assessed or that a specific treatment was implemented immediately following the fall. A care plan initiated that same day addressed the resident’s potential for alteration in skin integrity with general preventive interventions such as turning and repositioning, heel offloading, pressure-reducing surfaces, and incontinence care, but it did not include a problem or interventions specific to the right buttock bruise and coccyx skin tear sustained from the fall.

Subsequently, a treatment order for the right buttock/coccyx area was entered the day after the fall to cleanse with normal saline, pat dry, and apply Triad cream every shift and as needed for a skin tear related to the fall. Several days later, the wound team CNP evaluated the right buttock wound and classified it as a pressure ulcer with 100% yellow, soft slough and moderate serous drainage, measuring 4.5 cm by 2.5 cm with depth unable to be determined. Weekly wound documentation on that date described the wound as an unstageable pressure ulcer with intact periwound skin, and the treatment was changed to Medihoney, calcium alginate, and a dressing. An air mattress was also ordered at that time. Despite the reclassification of the wound as an unstageable pressure ulcer and the addition of new pressure-relieving interventions, the resident’s care plan was not updated to include the identified pressure ulcer, the new wound treatment, or the air mattress. Interviews with the DON, Regional Director of Clinical Services, MDS coordinator, and CNP confirmed that the initial skin tear and bruising were not comprehensively assessed and that the care plan was not revised to reflect the development and treatment of the pressure ulcer, contrary to the facility’s pressure ulcer prevention and treatment policy, which requires care plan modification to reflect changes in condition and weekly wound evaluation and discussion by the IDT.

The facility’s policy on Pressure Ulcer Prevention and Treatment Protocol states that residents with a Braden score of 12 or less are considered high risk for pressure ulcer development and that residents who develop a pressure ulcer must have appropriate nutritional evaluation, wound care interventions per protocol or MD orders, referrals as needed, and care plan modifications to reflect changes in condition. The policy also requires daily monitoring of periwound skin, weekly wound measurements, and weekly IDT discussion of wound status, with adjustments to treatment as needed. In this case, the resident, who was identified as high risk on admission, developed a wound to the coccyx/right buttock area following a fall that was initially documented as a bruise and skin tear but not fully measured or assessed, and the care plan was not updated when the wound was later classified as an unstageable pressure ulcer and new interventions were ordered. These omissions constitute the failure to provide appropriate pressure ulcer care and to prevent new ulcers from developing as cited in the deficiency.