F0686

G

Failure to Provide Consistent Assessment and Treatment of Pressure Ulcer

Geneva, Ohio Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, individualized pressure ulcer prevention and treatment program for a resident with multiple comorbidities and severe functional dependence. The resident was legally blind, had osteoarthritis, dysphagia, heart disease with heart failure, COPD, chronic kidney disease, anemia, depression, anxiety, and a history of repeated falls and acute respiratory failure. She was severely cognitively impaired, dependent on staff for toileting, bathing, bed mobility, and transfers, had an indwelling urinary catheter, and was frequently incontinent of bowel. Despite these risk factors, the care plan for impaired skin integrity did not translate into consistent, accurate assessment and documentation of her coccyx pressure ulcer, and the 5‑Day MDS inaccurately documented that she had no pressure ulcers and no nutritional or hydration interventions for skin problems, even though she had a Stage II coccyx ulcer on readmission.

The resident returned from the hospital on one occasion with a Stage II coccyx pressure ulcer that was not measured or described, and early treatment orders (e.g., zinc and foam dressing) were not documented as completed on multiple days. On a subsequent readmission, the coccyx wound was documented as Stage I with minimal description, and treatment orders again were not documented as completed on specified dates. By 10/13, the wound had progressed to a Stage III ulcer with 100% slough, and although wound care orders and nutritional supplements were initiated, the Prostat supplement was discontinued due to refusals. After another hospitalization, the resident returned with a Stage II coccyx ulcer and a suspected deep tissue injury to the buttock; wound care orders were in place and documented through the end of October, but the weekly wound summary on 10/31 showed the coccyx ulcer worsening in size and appearance and the buttock injury enlarging.

In November, there were significant lapses in wound assessment and treatment implementation. From 11/08 through 11/21, there were no treatment orders or documented treatments for the coccyx wound, and there were no wound assessments between 10/31 and 11/13, and then no documented coccyx treatments from 11/13 through 11/20, despite a 11/13 note describing the coccyx as a Stage III ulcer with 90% slough. On 11/21, the coccyx wound was found to have deteriorated to an unstageable ulcer with 100% slough, erythema, and warmth, requiring sharp debridement and extensive diagnostic workup. The DON later confirmed that there was no in‑house wound care team for several months, that an LPN who could not stage wounds was performing wound assessments with RN assistance, and that orders were not transcribed, resulting in a lapse of treatment during the transition between wound care providers. The CNP acknowledged awareness of the gap in wound care from late October to late November and noted the resident’s poor intake and refusals to get out of bed, while the dietitian described ongoing weight loss, fluctuating supplement acceptance, and concerns about the resident’s nutrition and wound status since October. These combined assessment, documentation, and treatment failures led to the worsening of the resident’s coccyx pressure ulcer from Stage II to Stage IV.