Failure to Assess and Document Sacral Pressure Ulcer and Provide Ordered Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to properly assess and treat a newly identified sacral pressure ulcer for a resident with multiple comorbidities, including a recent left above-knee amputation and history of stroke. On admission, documentation showed a surgical wound with staples to the left thigh, dry and cracked skin on the right foot, discoloration and scarring on the right leg, bruising on the right ankle, and buttocks free of skin breakdown. An admission MDS indicated moderately impaired cognition and dependence on staff for bed mobility, toileting hygiene, and transfers, with no pressure ulcers noted but a surgical wound present. Subsequent skin assessments by a nurse on two dates in December documented only a very thin area of pink and white tissue on the buttocks, consistent with previously healed wounds and no open areas, with staff providing protective skin care after incontinence. On a later date in December, a nurse documented that the resident was noted with a sacral wound, that wound care orders were obtained from the Medical Wound Provider, and that wound care was completed as ordered; however, the note did not include any description of the wound’s stage, characteristics, or presence of pain. A physician order was entered to cleanse the sacral wound with wound cleanser, apply calcium alginate to the wound bed, and cover with a dry dressing daily and as needed, but this order did not appear on the MAR or TAR. Review of the medical record showed no documentation that the ordered sacral wound care was provided on three consecutive days following the initial order. The nurse who obtained the order stated she entered it into the EMR and that it required activation to appear on the MAR or TAR, but she could not recall if she had activated it, could not recall measuring the wound, and only documented the new skin breakdown in a nursing note without detailed description. Interviews and record review confirmed that other nursing staff, including the nurse who later became the wound care nurse, could not recall providing wound care to the resident on the days in question and indicated that, at that time, floor nurses were responsible for wound care and the Medical Wound Provider was responsible for measuring and assessing wounds. The wound care nurse and another nurse explained that if an order was not activated in the EMR, it would not populate to the MAR or TAR, and staff would not know to complete the treatment. Observation of the resident’s buttocks in February showed a small area of pink and white scar tissue on one buttock and a very small, shallow open area with a pink/red wound bed on the other buttock, with wound care then being completed as ordered. The DON, who assumed the role later, stated she was unaware that the sacral wound care orders from late December had not populated to the MAR or TAR and stated she would have expected wound care to be completed as ordered and for the nurse to have documented a description of the wound in the progress note.
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