Inadequate Wound Care Competency and Documentation for Sacral Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed staff possessed and used appropriate wound care competencies for a resident who was readmitted with a sacral pressure injury. The resident had multiple diagnoses, including muscle weakness, a Stage III sacral pressure ulcer, anemia, and Alzheimer’s disease, and had fluctuating capacity to understand and make decisions. Assessments showed the resident had high risk for pressure ulcers due to occasionally moist skin, chairfast activity level, very limited mobility, and dependence on staff for toileting and bathing. Upon readmission, the interfacility transfer report from the hospital specified a wound care regimen using Vashe, Therahoney, and Optifoam for the sacral Stage III pressure injury, but the facility’s clinical admission assessment only noted a sacral wound with redness and did not describe the wound’s appearance or measurements, and the documented pressure ulcer section was left blank. Subsequent facility documentation showed inconsistencies and omissions in wound assessment and care planning. A skin and wound evaluation the day after readmission described a medical device–related pressure injury on the sacrum with specific measurements and characteristics, and listed xeroform as the primary dressing, which differed from the hospital’s transfer instructions. The resident’s care plan after readmission did not include interventions addressing the sacral pressure injury, despite the presence of the wound. Physician orders later directed cleansing the sacral pressure injury with normal saline, applying Santyl, and covering the wound. Over time, the wound progressed from a deep tissue pressure injury with smaller measurements to an unstageable pressure injury with larger dimensions and a wound bed containing both epithelial tissue and slough, with documentation of violaceous skin and concern for possible osteomyelitis. Interviews and record reviews revealed gaps in the treatment nurse’s wound care competencies and documentation practices. The treatment nurse stated that all licensed nurses were responsible for initiating and implementing resident-centered care plans when wounds were identified, yet acknowledged that the resident had no care plan interventions for the sacral pressure injury on readmission. The treatment nurse did not understand the term “violaceous” in the wound physician’s assessment and incorrectly equated it with simple skin redness, and stated that without understanding prior wound assessments, she would not know if the wound was improving or worsening. She also admitted to mistakenly signing the treatment administration record for providing sacral wound care on a day she was off duty and confirmed she never photographed the resident’s pressure injury, despite a job description requiring photographs of residents with specified pressure ulcers. The wound physician reported concerns about the quality of the treatment nurse’s assessments, noting her inability to differentiate violaceous skin from redness, and the medical records director confirmed there were no wound photographs in the resident’s record, contrary to facility policy and job expectations.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.