Failure to Ensure Timely Orders and Accurate Documentation for Sacral Pressure Injury Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for a resident admitted with multiple wounds, including a sacral pressure injury. On admission, the nurse assessed the sacral wound as a stage 2 pressure ulcer, and there were no corresponding treatment orders entered into the EMR for this wound until several days later. The resident’s diagnoses included COPD, vasculitis limited to the skin, and cellulitis of an unspecified limb. The facility’s skin and pressure injury prevention policy required Braden risk assessments on admission and at specified intervals, and the admission MDS documented a stage 2 pressure ulcer under Section M. However, a wound care provider’s assessment on the day after admission identified the sacral wound as unstageable due to necrosis, and a subsequent wound evaluation documented the sacral wound as unstageable, later reflected in the care plan as a sacral stage 4 pressure injury with necrotic tissue. The wound care provider’s assessments dated shortly after admission were not uploaded into the record until well after the MDS assessment reference date look-back period, so the MDS assessor only had access to the initial admission nurse’s stage 2 documentation when completing the MDS. A medication order for Santyl ointment and associated dressing care to the sacrum was obtained by a supervising RN from an on-call PA and entered into the EMR to start the following day, but the RN reported performing a dressing change on the date the order was obtained without documenting this treatment in a nursing note. These documentation gaps and delays in entering wound assessments and treatment orders resulted in the resident not having timely, clearly ordered, and consistently documented wound care in accordance with professional standards and the facility’s own skin integrity procedures.
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