Failure to Provide Ordered Treatment and Complete Assessment for Coccyx Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered treatment and adequate assessment for a coccyx pressure ulcer in one resident. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, chronic kidney disease, and left hemiplegia. A Weekly Pressure Ulcer Injury Record dated 11/3/25 documented a Stage II coccyx pressure ulcer measuring 1 x 0.3 cm, and the resident’s care plan dated the same day included interventions such as providing treatment as ordered to promote comfort and prevent infection. The physician’s order summary directed staff to apply moisture barrier cream to the buttocks and coccyx pressure ulcer every shift and as needed. During interviews and record review, it was determined that nursing staff did not consistently follow these orders or perform complete wound assessments. One LVN stated he did not perform treatments on the night shift and, when he assessed the coccyx ulcer on 11/12/25, he observed a small open area but did not measure it, only taking a quick look. Another LVN, who completed the weekly assessment dated 11/19/25, documented a Stage II coccyx pressure ulcer but did not measure it, explaining that she believed it had already healed and that she only noted the ulcer as a reminder of its prior existence. The facility’s pressure ulcer policy required monitoring wound status with each dressing change and documenting wound assessment parameters, including wound size and depth, using a quantitative tool such as the Bates-Jensen Wound Assessment Tool, which was not followed in these instances.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.