Failure to Timely Assess and Clarify Pressure Ulcer Versus MASD
Penalty
Summary
The deficiency involves the facility’s failure to accurately and timely assess, monitor, and treat a pressure ulcer for one resident with significant impairments. The resident was admitted with paraplegia/functional quadriplegia, dementia, cancer, severe cognitive impairment, and total dependence for ADLs, transfers, and bed mobility. On admission, documentation showed a Stage 2 pressure ulcer on the coccyx/sacrum area measuring approximately 2.5 inches by 0.1 inch, with a horizontal open area noted on the skin assessment. Provider notes from the SNF recommended repositioning every two hours and monitoring skin integrity, especially the sacral area. However, from admission through 12/27/2025, the medical record contained no wound care orders for the documented Stage 2 pressure ulcer. Further record review showed no weekly skin assessment documentation between 12/15/2025 and 12/28/2025, despite facility policy requiring weekly wound monitoring and documentation. On 12/27/2025, a nurse progress note indicated a sacral wound was present after CNA notification during ADL care. A weekly skin evaluation on 12/28/2025 documented a Stage 2 pressure ulcer on the sacrum, and a 12/29/2025 note described a new Stage 2 pressure area and referenced a healed Stage 4 pressure area in the same region. On 12/30/2025, the wound consultant assessed a wound on the left buttock, diagnosed as MASD and non-pressure related, located on the fleshy part of the buttock extending from left to right, and reported being unaware of any coccyx/sacral wound or prior healed Stage 4 ulcer. Staff interviews confirmed that weekly skin assessments were expected but not completed in the week after admission, that the record was unclear whether the sacral and buttock wounds were the same, and that the resident had an open wound on the bottom since admission, with frequent refusals to reposition.
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