F0686

D

Failure to Assess and Document Pressure Ulcer Care

Pittsburgh, Pennsylvania Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to assess and provide necessary treatment and services for a resident’s pressure ulcer in accordance with its wound management policy and professional standards of practice. The facility’s Wound Management Program policy required comprehensive wound care, including visual skin assessments on admission, readmission, and as needed, with documentation in the Nursing Admission Screening and/or Skin Observation Tool. For one resident with diagnoses including anxiety, depression, and adult failure to thrive, the clinical record showed a physician order for weekly head-to-toe skin assessments at bedtime every Thursday. However, review of the clinical record revealed that the skin observation tool was not completed for this resident between 9/15/25 and 12/20/25, despite the standing order for weekly skin assessments.

Further record review showed that on 12/20/25 a physician ordered daily sacral wound care, specifying cleansing with normal saline and application of Medi honey, calcium alginate, and bordered gauze. The December treatment administration record did not show documentation that this dressing was completed until 12/22/25. A subsequent physician order dated 12/22/25 changed the sacral wound treatment to cleansing with soap and water and covering with a dry dressing daily and as needed on the night shift. The December treatment administration record showed that this dressing was not documented as completed on 12/30/25. In an interview, the DON confirmed the absence of documented skin assessments over the specified three-month period and the missed or undocumented wound treatments on the identified dates, supporting the finding that the facility failed to ensure appropriate assessment and treatment for the resident’s pressure ulcer.