F0684

D

Failure to Prevent, Assess, and Treat MASD and Sacral Skin Breakdown

Prescott, Arizona Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent, assess, and treat moisture associated skin damage (MASD) for one resident in accordance with physician orders, facility policy, and professional standards. The resident was admitted with multiple comorbidities, including a periprosthetic fracture around an internal prosthetic left knee, left femur fracture, COPD, pneumonia, atrial fibrillation, breast cancer, and a need for assistance with personal care. An initial admission assessment documented no skin problems, and a care plan and physician orders were put in place for pressure ulcer risk, including frequent repositioning, barrier cream to the perineal area every shift, weekly skin evaluations, and weekly Braden Scale assessments. Early documentation on daily skilled notes and Braden assessment indicated no skin issues and low risk for pressure-related skin impairment, despite the resident being dependent for toileting hygiene and having incontinence.

Within days of admission, multiple staff documents and shower sheets began to note redness and abnormal skin color on the lower back and coccyx area, as well as redness, rashes, open areas, and skin tears in the genital and sacral/coccyx regions. These findings were recorded on March 7, 8, and 12 by CNAs and nurses, and an Occupational Therapist documented decubitus ulcers on the inner thighs, vagina, buttocks, and right heel, along with improper healing of a pelvic incision. However, there was no evidence that the redness and skin changes on the lower back and coccyx were communicated to the physician at those times, and provider progress notes repeatedly described the skin as warm and dry without rashes, lesions, or wounds. There was also no evidence of detailed skin assessments or change-of-condition monitoring orders when significant redness, rashes, open areas, and bleeding were documented on shower sheets. Nursing documentation was inconsistent, with several days lacking daily skilled notes, and some weekly skin assessments and non-pressure ulcer assessments created later and backdated, omitting the sacral/coccyx issues.

Physician orders for skin care, including barrier cream to the perineal area every shift and frequent repositioning, were not consistently documented as completed on the MAR/TAR for multiple day shifts. Required weekly skin evaluations and Braden Scale assessments were missed or not documented as completed according to the orders, with only the initial Braden assessment and one later assessment recorded. When a coccyx skin injury/ulcer and MASD to the coccyx and upper rear thighs were eventually documented, there were no early measurements or detailed descriptors, and the onset date for the sacro-coccyx MASD wound was later recorded as March 19 with a 6 cm x 5 cm partial thickness wound and peripheral tissue edema. Staff interviews revealed that CNAs and nurses were aware of raw, red, painful, and bleeding skin on the perineal and sacral areas, and that the resident experienced excruciating pain during pericare. Staff also reported that there were times when there were not enough staff to change and reposition the resident every two hours as expected, and that management had been informed of staffing concerns. The wound nurse acknowledged that, based on the documentation, he could not determine when he first assessed the wound, its progression, or whether it was improving or worsening, and the ADON confirmed that the documentation did not meet expectations for identifying, assessing, and treating the resident’s skin condition.

Throughout this period, multiple provider progress notes continued to state that the resident’s skin was warm and dry without rashes, lesions, or wounds, even on days when other documentation or staff interviews indicated significant MASD, excoriation, open areas, and bleeding on the sacral/coccyx and perineal regions. The facility’s own policies on wound management, physician orders, documentation and charting, and change of condition reporting required comprehensive assessments, accurate transcription and implementation of orders, complete documentation of care and resident status, and prompt communication of changes in condition to the physician. The clinical record and staff interviews showed that these processes were not consistently followed for this resident, resulting in delayed and incomplete assessment and treatment of MASD and related skin breakdown.

The CNA task log for turning and repositioning showed missing entries for required repositioning on certain shifts, and staff interviews indicated that CNAs were expected to check incontinent residents at least every two hours and that nurses were to perform weekly skin checks and notify the wound nurse of any issues. Despite these expectations, there were gaps in documentation of repositioning, missed or incomplete weekly skin assessments, and delayed or absent communication to the provider and wound nurse about the resident’s worsening sacral and perineal skin condition. The ADON and wound nurse both acknowledged that the available documentation did not allow them to determine the wound’s progression or whether interventions were effective, and that the documentation and response to the resident’s MASD did not meet their expectations for quality of care and prevention of worsening skin conditions.