F0686

G

Failure to Prevent and Timely Assess a Facility-Acquired Stage III Pressure Ulcer

Kokomo, Indiana Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent the development of a pressure ulcer and to complete a timely wound assessment for a resident who was admitted without pressure ulcers. The resident had multiple diagnoses including Parkinson’s disease, history of falls, incontinence, gait and mobility abnormalities, muscle weakness, and diarrhea. The ETAR for November showed that a hydrocolloid dressing was used on the coccyx as a preventive measure from the 1st to the 15th, but there was no physician order or documentation of any preventive dressing from the 15th through the 26th. On the 27th, a hydrocolloid dressing was documented as being applied to the tailbone after cleansing a wound, indicating that an open area had already developed.

The resident reported that staff discovered the sore on the coccyx during bathing, after he had complained of soreness in that area. A nursing progress note on the 28th documented that the resident refused to get out of bed and resisted turning and repositioning, despite being educated on the importance of offloading pressure. A facility pressure injury document dated the 28th at 4:00 p.m. indicated staff had reported a new area on the coccyx to the wound nurse, and that the resident was unaware of the area. This document also stated that the wound was found on the night of the 26th at 10:30 p.m., but there was no clinical record entry on the 27th describing who found the wound, the time it was found, its measurements, or wound characteristics.

A wound summary dated the 28th at 4:38 p.m. documented that the resident had a facility-acquired Stage III pressure ulcer on the coccyx, with specific measurements and tissue description, and identified pressure as the cause. Subsequent hospital and wound physician documentation described the same coccyx/sacral wound as an unstageable pressure injury at one point and later as a Stage III ulcer with changing measurements and tissue composition. The facility’s skin assessment policy required that when pressure or other skin conditions are identified, a wound assessment be initiated and documented in the chart, with the initial observation described in nursing progress notes and measurements obtained using appropriate tools. The lack of timely documentation and assessment on the date the wound was first identified, combined with the gap in documented preventive measures, led to the cited deficiency for failure to ensure a resident without a pressure ulcer did not develop one and that a wound assessment was completed when the wound was discovered.