F0686

G

Failure to Assess, Treat, and Document Pressure Ulcers and Prevent Worsening Wounds

Buffalo, Missouri Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and preventive services consistent with professional standards for a resident who was at risk for skin breakdown and later developed extensive pressure-related wounds. The resident had spina bifida with paralysis, neuromuscular bladder dysfunction, a history of UTIs and sepsis, and required substantial to maximum assistance with ADLs and mobility. The resident’s MDS indicated intact cognition, no existing pressure ulcers, risk for pressure ulcers, and a need for pressure-reducing devices for bed and chair. The care plan directed staff to assess, record, and monitor wound healing as ordered, measure wounds, document wound bed and perimeter, report changes to the MD, and follow facility policies for prevention and treatment of skin breakdown.

On a weekly skin assessment dated early in the month, staff documented no open areas and no pressure-reducing devices in use, with only skin discoloration on the left buttock. A few days later, the DON documented being called to the resident’s room for an open coccyx area and applied a foam dressing, but there was no documented full wound description, no measurements, and no documentation of MD notification or treatment orders for this new area. The POS for that month did not contain orders for pressure-reducing devices or for treatment of the new coccyx wound, and no new skin assessment was completed after the earlier weekly assessment. The care plan was not updated to reflect the new coccyx wound, and progress notes for the following week contained no wound assessments or documentation related to the open area.

Later in the month, a nurse documented that the resident’s coccyx, sacrum, and bilateral buttocks were open, red, irritated, and weeping serous drainage, and that the MD was notified and wound care orders were received and applied. However, this note still lacked wound measurements and a detailed wound description, and the new wound orders were not entered on the POS. A physician progress note documented ulcerations to the coccyx, sacrum, and bilateral buttocks and the need for a wheelchair cushion for pressure reduction, but no order for a pressure-reducing cushion was documented on the POS. A subsequent wound assessment recorded multiple open areas on both buttocks with specific measurements and daily dressing changes, but again without detailed descriptive characteristics. Shortly thereafter, the resident was hospitalized, and a surgery consult described excoriated sacral skin, necrotic-appearing tissue near the anus, and foul-smelling purulent drainage.

Interviews with CNAs, nurses, and other staff showed inconsistent understanding and implementation of wound assessment and documentation practices. CNAs and other staff described the buttock wounds as looking like “hamburger meat,” oozing, bleeding, with odor and blackened areas, while RNs and LPNs acknowledged that nurses were responsible for wound care, assessments, and documentation. Staff reported that an ADON had previously completed weekly wound assessments and that after the ADON’s departure, expectations for who would perform and document weekly wound measurements were unclear. One LPN who completed a weekly wound assessment stated that measurements were documented on paper and should have been entered into the EMR but was unsure how regularly wounds should be monitored or documented. The DON stated she expected weekly skin and wound assessments with measurements, MD notification for new open areas, and documentation of assessments, but indicated she did not become aware of the wounds opening until around the middle of the month. The Administrator stated an expectation that wounds and skin be assessed, monitored, measured, documented, and that care plans be individualized, which did not occur in this case.