F0686

G

Failure to Initiate, Monitor, and Document Pressure Ulcer Care Leading to Worsening Wounds

Aztec, New Mexico Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely and consistent pressure ulcer treatment and monitoring for a resident, resulting in the development and worsening of pressure ulcers. The resident was admitted without documented pressure ulcers but was identified on 10/28/25 as having a new coccyx/sacral wound with blood noted on the gown. Despite this identification, there were no wound care orders in place from 10/28/25 through 11/06/25, and the wound was initially documented only as a skin tear or MASD in weekly skin checks without detailed description. The Wound Care Nurse later confirmed that no orders or treatments were completed for the coccyx/sacral wound from 10/29/25 to 11/07/25, and she was not made aware of the wound until 11/04/25.

Once wound care orders were initiated in November, staff failed to consistently administer and document the ordered treatments. The Treatment Administration Records show multiple dates in November, December, and January where wound care for the coccyx/sacral wound was not documented as completed, and no codes were entered to indicate refusal or other reasons for omission. Weekly wound assessments by the Wound Care Nurse were also missed, including the week of 11/10/25, and subsequent assessments documented progression from MASD to Stage 3 and then Stage 4 pressure ulcer with heavy purulent exudate, slough, tunneling, and signs of infection. The resident’s NP and MD notes documented an infected coccyx/sacral wound requiring debridement and antibiotics, and the resident was ultimately transferred to the hospital with osteomyelitis and sepsis related to the coccyx/sacral pressure ulcer.

The facility also failed to timely identify and treat a new left ischial/buttock wound. A weekly skin check on 12/26/25 documented a pressure wound to the left buttock, but the Wound Care Nurse later stated she was unaware of this finding and did not know how long the left ischial wound had been present. The Assistant DON acknowledged that the wound did not develop overnight and had been missed by staff. The left ischial wound was not documented on January weekly skin checks, and wound care orders for this area were not obtained until 01/14/26, after the Wound Care Nurse observed sores on the resident’s backside. The Wound Care Nurse’s assessment on 01/15/26 described the left ischial wound as unstageable, large, mostly slough, and boggy, and the TAR again showed missed and undocumented treatments for both the coccyx/sacral and left ischial wounds. CNAs reported seeing wounds and redness, including a wound with odor, and stated they informed nurses, while the ADON and Wound Care Nurse confirmed that staff failed to notify them promptly and that nurses did not understand or follow skin assessment and wound care processes.

Throughout the period, the resident required assistance with mobility and repositioning and experienced significant pain with turning, sometimes refusing care, air mattress use, and IV antibiotics. However, the care plan entries documenting the resident’s self-determination and refusals were initiated later, and there was no consistent documentation on the TAR to show when wound care was refused versus not provided. The facility’s leadership, including the ADON and DON, acknowledged that wound care orders were not followed or documented as expected, that wound locations were initially documented incorrectly, and that the left ischial wound should have been identified and treated sooner. The cumulative inactions included delayed initiation of wound care after initial wound identification, inconsistent performance and documentation of ordered treatments, missed weekly wound assessments, and failure to timely recognize and report a new pressure wound, all of which led to the resident’s pressure ulcers worsening and requiring hospitalization for advanced wound care and surgical debridement.