F0686

D

Failure to Care Plan and Manage Sacral Pressure Injury Resulting in Wound Worsening

Los Angeles, California Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary services and resident-centered care planning to manage and promote healing of a sacral pressure injury for one resident. The resident was admitted and later readmitted with diagnoses including muscle weakness, a Stage III sacral pressure ulcer, anemia, and Alzheimer’s disease with fluctuating decision-making capacity. An interfacility transfer report from an acute care hospital specified a detailed wound care regimen for the sacral Stage III pressure injury, including cleansing with Vashe, application of Therahoney, and coverage with Optifoam. Upon admission, the facility’s clinical admission assessment documented a sacral wound with redness but did not include a description of the wound’s appearance or measurements, and the section for documented pressure ulcers was left blank.

A subsequent skin and wound evaluation identified a medical device–related pressure injury at the sacrum with specific measurements and characteristics, but the primary dressing listed was Xeroform, differing from the hospital’s recommended treatment. The resident’s existing care plan addressed only a general risk for potential impairment to skin integrity related to anticoagulant use, poor bed mobility, and advanced age, with broad interventions such as education, encouraging nutrition and hydration, following facility protocols, and keeping skin clean and dry. After the resident’s readmission, there was no care plan with specific interventions for the sacral pressure injury, and the turning program and wound treatments were not incorporated into the care plan. Physician orders were written to cleanse the sacral pressure injury with normal saline, apply Santyl, and cover, but these changes and later modifications were not reflected in updated care plan interventions.

Over time, the resident’s sacral wound worsened. Skin checks documented that the sacral pressure ulcer became unstageable and increased in size from the initial measurements to 4 cm by 4.5 cm. Wound physician assessments showed progression from a deep tissue pressure injury to an unstageable wound with a mix of epithelial tissue and slough, violaceous skin, and concern for further decline, prompting an order for an x-ray to evaluate for osteomyelitis. Interviews with the treatment nurse and an RN confirmed that nursing staff did not create a resident-specific care plan for the sacral pressure injury at admission and did not update the care plan when the wound worsened or when physician orders changed. The wound physician stated that the resident’s risk factors, including incontinence, muscle weakness, and cognitive limitations, placed the resident at high risk and that the wound was not assessed and measured by nursing staff upon admission. The registered dietitian reported that neither she nor the dietary department addressed the pressure injury after it was identified, and no RD assessment or nutritional recommendations were made despite facility policy requiring RD evaluation upon significant changes in skin condition. Facility policies on skin integrity management, comprehensive person-centered care planning, and the treatment nurse’s job description all required development and updating of a plan of care, weekly skin evaluations, RD involvement, and interdisciplinary discussion, which were not implemented for this resident’s sacral pressure injury.

The facility’s failure to develop and update a comprehensive, resident-centered care plan for the sacral pressure injury, to accurately assess and document the wound on admission, to integrate physician orders into the care plan, and to involve the RD and IDT as required by policy resulted in the resident’s sacral wound worsening. The report states that this failure resulted in the resident’s worsening sacral wound condition and placed the resident at risk for wound infections and other complications, including hospitalizations.