F0686

G

Failure to Timely Assess and Implement Interventions for New Pressure Ulcers

Minneapolis, Minnesota Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly assess and treat newly developed skin breakdown and to timely implement ordered interventions for pressure ulcer care for one resident. The resident initially had intact skin documented on a weekly skin inspection at the end of November, and a significant change MDS in early December showed no unhealed pressure ulcers, though it noted a recent fall with wrist fracture and increased need for assistance. A Braden assessment shortly after the fall scored the resident as low risk, despite dementia, diabetes, stage III kidney disease, incontinence, and increased dependence with mobility and transfers.

On 12/6, a weekly skin inspection documented an “ongoing open area on left buttock” but did not include measurements, wound characteristics, or any treatment provided. A subsequent CAA signed 12/11 stated the resident did not have any pressure ulcers, even though it identified the resident as at risk for skin breakdown. On 12/11, another weekly skin inspection noted redness and a wound to the scrotum, again without clarifying whether this was the same area as previously documented or whether the earlier area had healed, and without documenting any treatment. On 12/12, skin issues were formally measured and recorded as MASD on the sacrococcygeal area and left gluteus, and another note the same day identified MASD to the scrotum and left buttocks with a plan for barrier cream, but there was no corresponding documentation on the TAR to show that barrier cream was consistently applied.

On 12/16, a wound care PA evaluated the resident and documented scattered erosions over the right buttock and sacrum, with MASD to the buttock/sacrum, and recommended meticulous pericare, Triad paste BID and PRN, repositioning per Braden protocol, initiation of an APM, and RD review of nutritional needs. The record shows Triad paste treatments beginning 12/17, but the APM and RD evaluation were not implemented at that time. By 12/23, the sacrococcygeal area had progressed to an unstageable pressure ulcer with necrotic tissue, and the wound care PA again documented that the requested APM was not in place, re-requested it, and again asked for RD evaluation and wound-healing supplements. The care plan was not updated with new skin interventions until 12/24, and the APM was not documented as in place until 12/29, despite being readily available. Throughout December, provider regulatory visits did not address the resident’s skin condition, and Braden scoring continued to rate the resident as low risk. By 12/30, skin assessments documented multiple unstageable pressure ulcers and additional MASD areas, with the sacral wound significantly enlarged and new pressure ulcers on the buttocks, while the IDT did not complete a comprehensive assessment of the initial buttock wound identified on 12/6 or its progression from MASD to pressure ulcer until after the resident was hospitalized in early January.

The facility’s own policy on Skin Assessment & Wound Management required that when a new pressure wound is found, staff notify the provider, initiate a skin and wound evaluation, refer to dietary as needed, and review and update the care plan interventions. The record lacked evidence that these steps were carried out when the first open area was documented on 12/6 or as additional areas and worsening wounds were identified. The TAR showed that the first documented treatment for the developed skin breakdown did not begin until 12/17, despite earlier documentation of open areas and MASD. Recommendations from wound care providers for an APM and RD evaluation were not acted upon for weeks, and the IDT did not complete a pressure injury root cause analysis or comprehensive review of the wounds until after the resident had been transferred to the hospital and did not return. Interviews with nursing staff and leadership confirmed that the root cause analysis process was not initiated when the wounds first developed and that the RD was not notified in a timely manner of the need for nutritional evaluation related to the resident’s wounds.