F0686

D

Failure to Assess and Treat Known Sacral Pressure Ulcer

Elgin, Illinois Survey Completed on 12-04-2025

Penalty

No penalty information released

Summary

The facility failed to assess, monitor, and obtain treatment orders for a resident with a known sacral pressure wound. The resident was admitted with multiple comorbidities, including a prior surgical amputation of the left foot due to a foot ulcer, type II diabetes mellitus, peripheral vascular disease, congestive heart failure, and other chronic conditions. The resident was cognitively intact but totally dependent on two staff for transfers and required partial to moderate assistance with bed mobility. Hospital records immediately prior to admission documented a sacral pressure wound measuring 7 cm x 8.5 cm x 0.1 cm, described as purplish, non-blanchable erythema and an open deep tissue injury. Despite this, on admission and during a comprehensive skin assessment on 11/25/25, only the left lower extremity amputation wound was documented, and no sacral wound was recorded.

During incontinence care observed on 12/1/25, staff noted an undated bordered foam dressing on the resident’s sacrum that appeared old and was peeling. A CNA removed the dressing and notified the nurse. The wound care nurse initially believed the dressing was a pain patch, then, upon assessment of the sacrum, identified a pressure wound with slough and a small area of granulation, measuring 9 cm x 8.5 cm x 0.1 cm. The wound care nurse stated she had not been informed of the sacral wound and that it had not been present at her last assessment. Review of the physician order sheet and treatment administration records for November and December showed no treatment orders for a sacral pressure wound, and the care plan contained no interventions for a sacral wound. The facility’s own clinical protocol required skin examination of new admissions for ulcerations and physician-authorized wound treatment orders, but these were not implemented for this resident’s sacral pressure ulcer.