Failure to Assess, Document, and Treat a New Sacral Deep Tissue Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services for a resident with a newly identified sacral deep tissue pressure injury (DTPI). The resident had multiple diagnoses including cerebral infarction, dysphagia, reduced mobility, diabetes, malnutrition, and other conditions, and Braden/pressure risk scales completed on several dates showed the resident was at risk for pressure ulcers. On 1/19/26, the wound care nurse documented that therapy staff notified her of a skin condition on the buttocks, and she assessed a DTPI to the sacral region measuring 1.20 cm by 0.40 cm with unknown depth. Despite this, the physician order sheet contained no orders for treatment or management of the sacral wound, the treatment administration record for the month showed no wound treatment, and the care plan contained no problem statement, goals, or interventions related to the sacral wound. Staff interviews further showed that the wound was not consistently recognized or acted upon. The LPN who was the resident’s nurse prior to transfer to the hospital stated she only assessed the resident’s front side for skin issues, did not turn the resident because she could not do so alone, and was unaware of any sacral wound. The wound care nurse stated that the occupational therapist had reported a reddened area on the tailbone, that she assessed the sacral wound, and that she informed the physician, but review of the record revealed no documentation of physician or family notification and no physician orders for the DTPI. She acknowledged she did not carry out physician orders and stated she “must have forgot,” and also stated that when a resident acquires a new wound, the family and physician should be notified and the conversation documented. The DON reported she did not recall the resident having a wound and described that, per facility practice and policy, new wounds should be communicated via the communication board, physician orders, progress notes, and assessments, with physician and family notification documented. The facility’s wound prevention and healing policy required wound care treatments under physician direction and oversight by certified wound care nurses, which was not reflected in the resident’s record for this sacral DTPI.
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