Failure to Care Plan for Resident’s Buttock Pressure Ulcers
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident with documented pressure ulcers. The resident, a 65-year-old female admitted with a diagnosis of a sacral pressure ulcer, had an admission MDS that incorrectly indicated she did not have any unhealed pressure ulcers or injuries. Her comprehensive care plan dated 01/30/2026 addressed deep tissue injuries to the right and left heels, with interventions such as a pressure-reducing mattress, skin care, treatment, and a turning and repositioning schedule, but it did not include any care plan problem, goals, or interventions for pressure ulcers to the right and left buttock areas. Further record review showed that a wound care assessment on 02/02/2026 documented stage 2 pressure ulcers on the resident’s left and right buttocks, and a physician’s order dated 02/04/2026 directed daily wound care to those areas using triad with collagen particles. Interviews with the hospital nurse confirmed the presence of stage 2 pressure ulcers to the buttocks, and the facility’s wound care LVN stated that the resident had unhealed stage 2 pressure ulcers to the left and right buttocks upon admission and that wound care was provided as ordered. The DON acknowledged that there was no specific care plan for the stage 2 buttock pressure ulcers and attributed this to an inaccurate MDS assessment, despite the facility’s policy requiring a comprehensive care plan with measurable objectives and timeframes for all needs identified in the comprehensive assessment.
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